BRIDGING AUTISM EVALUATION GAPS: A PARENT TRAINING APPROACH 

By 

Nicholas Hasome Ramazon 

A DISSERTATION 

Submitted to 
Michigan State University 
in partial fulfillment of the requirements  
for the degree of 

School Psychology – Doctor of Philosophy 

2025 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ABSTRACT 

Caregivers of children awaiting an evaluation for autism undergo increased levels of 

stress (Mulligan et al., 2012; Zukerman et al., 2015) and their self-efficacy with parenting is 

frequently impacted (Murphy & Harrison, 2022; Tang et al., 2015). Most interventions to date 

have focused on child outcomes while waiting for an evaluation for autism (Zukerman et al., 

2015). Very few studies have supported caregivers during the waiting list, while also measuring 

their outcomes (DesChamps, 2020).  

The present study examined the initial efficacy of C-HOPE as an interim service for 

caregivers of children waiting for an evaluation for autism spectrum disorder. A single group 

pre/post method was used to assess whether participation in C-HOPE reduced caregivers stress 

levels, increased caregiver self-efficacy, increased knowledge about behavior management and 

behavioral principles, and reduced child problem behaviors. A secondary aim was to measure the 

acceptability, feasibility, and appropriateness of the intervention.  

The results of this study provide preliminary but promising evidence supporting the 

efficacy and acceptability of the C-HOPE parent training program for caregivers of children 

awaiting an evaluation for autism. Statistically significant changes were observed across several 

outcome variables, including reductions in caregiver stress, increased caregiver satisfaction, 

increased knowledge about behavioral principles, and decreased child problem behavior 

intensity, with large effects sizes each. No significant effects were observed for caregiver self-

efficacy. There was an increase in efficacy on average, with a positive effect. Effects of C-HOPE 

on efficacy should be examined in future studies. Study implications and future research 

directions are provided.

 
ACKNOWLEDGEMENTS 

Completing this dissertation has been a journey filled with growth, learning, and 

perseverance, alongside caffeine, candy reinforcers, and naps in-between writing. I am deeply 

grateful to those who supported and encouraged me along the way, fueled these caffeine and 

sugar addictions, and allowed me to not feel guilty about taking naps.  

First and foremost, I would like to express my sincere gratitude to my advisor, Dr. Kristin 

Rispoli, for her guidance, thoughtful questions, and critical feedback. Your support challenged 

me to think deeper, write more clearly, and ultimately develop a more robust and meaningful 

study. I am thankful for your mentorship throughout every step of this academic journey. From 

our early supervision mornings to our presentations at conferences, I am thankful for all of the 

time you invested in me as your student. At graduation, you joked about my Background 

Screening Instructions for my skill in reservation making – I hope you know that skill will 

continue down the road when we attend conferences as colleagues.  

I would like to thank my dissertation committee members, Drs. Lee, Plavnick, and 

Volker, for their invaluable feedback and encouragement. Your insights strengthened my work 

and helped me refine my thinking in important ways. A special thank you to Dr. Volker for his 

weekend master classes on statistics.  

To my COVID-19 cohort, Shelbie Ghandi, Ersie Gentzis, and Shelby Brennan, thank you 

for being by my side since the beginning of this doctoral journey. We started this together, and it 

is so special that we are finishing together as well. Your camaraderie and friendship has made 

this experience infinitely better.  

Thank you to those who helped with running and analyzing the data from the data. Thank 

you, Shelby Brennan, for supporting this project by serving as an interventionist. Your 

iii 

 
dedication to the work and the families we served was crucial to the success of this study. Thank 

you also to Lauren Ziegelmeyer for your detailed and thoughtful work as a coder on the thematic 

analysis. Your contributions helped bring the caregivers' voices to life in meaningful ways. 

I am grateful to my lab mates for their feedback throughout the development, proposal, 

and defense phases of my dissertation. Your insights and encouragement helped me shape this 

project into what it is today. I am also thankful to Emma Nathanson, a graduate of the FSC 

Connection lab. Your continuous support, from guiding me through the dissertation process to 

sharing templates and providing reassurance when I needed it most, is appreciated.  

Thank you to the recruitment sites that allowed me to recruit participants for this project. 

Most importantly, I am deeply appreciative of the caregivers who participated in the study. Your 

willingness to share your experiences made this work possible, and I hope that this research will 

ultimately contribute to better systems for supporting families like yours. 

I would also like to acknowledge my internship cohort for holding me accountable 

through the final stretch,  for setting deadlines, for meeting me at coffee shops to type away at 

drafts, and for reminding me that I could, and would, finish. Thank you to my internship 

supervisors as well, for their flexibility, encouragement, and ongoing support in helping me stay 

on track while balancing clinical responsibilities. 

As a first-generation college student, I have been fortunate to lean on the guidance of my 

cousins, Samira and Samaneh, who paved the way before me. You not only embraced this shared 

identity, but also supported me in tangible ways, most notably by helping me refine my college 

essays during the early stages of my undergraduate application process… which later evolved 

into applications for a master’s degree, and now a doctorate. Your belief in me laid the 

foundation for my academic journey. I share this dissertation with deep pride and gratitude, 

iv 

 
hopeful that it will open doors for future generations in our family to pursue higher education 

with even greater confidence and opportunity.  

Finally, I am forever grateful to my parents, Ehsan and Bridget, for their love, 

motivation, and constant check-ins, even when you weren’t always sure what a dissertation 

defense or thematic analysis meant. Your support carried me through more than you know. 

This dissertation is a reflection of the many people who walked with me during this 

process, and I am truly thankful to each and every one of you  

v 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TABLE OF CONTENTS 

INTRODUCTION .......................................................................................................................... 1 

LITERATURE REVIEW ............................................................................................................... 7 

METHOD ..................................................................................................................................... 45 

RESULTS ..................................................................................................................................... 80 

DISCUSSION ............................................................................................................................... 96 

REFERENCES ........................................................................................................................... 131 

APPENDIX A: DEMOGRAPHIC FORM ................................................................................. 148 

APPENDIX B: PARENT KNOWLEDGE QUESTIONNAIRE ................................................ 153 

APPENDIX C: AIM/IAM/FIM .................................................................................................. 154 

APPENDIX D: PROCEDURAL FIDELITY FORMS .............................................................. 156 

APPENDIX E: POST-SESSION QUESTIONNAIRE ............................................................... 163 

APPENDIX F: FOCUS GROUP QUESTIONS ......................................................................... 164 

APPENDIX G: COMPASS PROFILE ....................................................................................... 165 

APPENDIX H: SESSION 5 FORM ........................................................................................... 171 

APPENDIX I: FOCUS GROUP CODE BOOK ......................................................................... 172 

APPENDIX J: CASE EXAMPLE #1 ......................................................................................... 174 

APPENDIX K: CASE EXAMPLE #2 ........................................................................................ 191 

vi 

 
INTRODUCTION 

Autism Spectrum Disorder (ASD)1 is a complex neurodevelopmental condition 

characterized by persistent deficits in social communication and interaction, along with restricted 

and repetitive behavioral patterns (American Psychiatric Association, 2013). Recent statistics 

indicate a notable increase in the prevalence of identified ASD cases, with approximately one in 

36 children diagnosed with ASD (Maenner, 2023). This rise in prevalence coincides with a rise 

in the need for evaluations (Crane et al., 2016).  

A prolonged waiting period for an ASD diagnosis is widely recognized as a barrier to 

timely access to services (Monteiro et al., 2019). Families awaiting autism evaluations often 

experience a lack of services until a formal diagnosis is obtained (Kanne & Bishop, 2021). This 

critical gap persists between the initial suspicion of ASD in a child and the commencement of the 

evaluation process (Craise et al., 2016), resulting in extended waiting lists (Kane & Bishop, 

2021) and a subsequent delay in essential services like early intervention. Timely intervention at 

this stage is paramount for achieving improved outcomes in children with ASD (National 

Research Council Committee on Grand Challenges in Environmental Sciences, 2001) 

Amidst this period of uncertainty, caregiver stress often increases (Jones et al., 2017). 

Those awaiting an ASD evaluation, as well as caregivers of children displaying early signs of 

ASD, often grapple with a range of challenging emotions (Graungaard & Skov, 2007; Mulligan 

et al., 2012; Zukerman et al., 2015). The lack of control over the process, combined with the 

unknown outcome, can lead to feelings of confusion and overwhelm (Rivard et al., 2014). 

Similarly, caregivers may face unique challenges when navigating the assessment process, 

further heightening their stress levels (Zukerman et al., 2015). 

The author recognizes the varying perspectives regarding terminology used to identify individuals 
diagnosed with autism spectrum disorder. person-first and identity-first language is intentionally used 
throughout this proposal to acknowledge the differing perspectives of individuals diagnosed with autism 
(e.g., Arnhart et al., 2022; Botha et al., 2021). 

1 

 
 
 
 
In conjunction with caregiver stress, self-efficacy is another pivotal variable in caregiving 

(Guimond et al., 2008). Caregiving self-efficacy, defined as the belief in one's ability to 

effectively manage caregiving responsibilities, plays a substantial role in the caregiver's 

experience (Coleman & Karraker, 1998). Studies have consistently shown that high levels of 

caregiver efficacy are linked to lower levels of stress, better caregiving outcomes, and positive 

mental health in caregivers of children with autism (DesChamps et al., 2020; Garcia et al., 

2016a; Kuhn & Carter, 2006; Rudelli et al., 2021; Tang et al., 2015). Conversely, low self-

efficacy can lead to depression, lack of motivation, and low self-esteem among caregivers 

(Bandura, 1982; DesChamp et al., 2020). Parent knowledge about how to manage child behavior 

problems can increase both self-efficacy (Keen et al., 2010; Kurzrok et al., 2021) and stress 

(Keen et al., 2010). 

Despite this information, limited interim services have emerged to support families 

during this critical waiting period. However, several early intervention and parent support 

programs exist for families once they receive a diagnosis. Early intervention programs are 

instrumental in identifying and addressing developmental delays associated with ASD, aiming to 

enhance overall functioning and quality of life (Brandson et al., 2008; Fuller & Kasier, 2019; 

Pickles et al., 2016). Additionally, caregiver support groups offer a cost-effective means of 

connecting caregivers with others facing similar situations, providing valuable strategies and 

insights (Clifford & Minnes, 2012; Conolly & Gersch, 2013; Mandell & Salzer, 2007). 

Furthermore, caregiver training and telehealth caregiver training present promising avenues to 

empower caregivers with evidence-based skills to support their children effectively (Akamoglu 

& Meadan, 2018; Gerow et al., 2023; Pickles et al., 2016; Wainer & Ingersoll, 2015). As the 

percentage of children with ASD increases and the evaluation waitlists grow, more interim 

2 

 
 
 
services will need to be made available for caregivers. In particular, brief, individualized, and 

hybrid modality (i.e., in-person and virtual) interim services that support positive development of 

caregiver self-efficacy and decrease caregiver stress, as well as decrease challenging child 

behaviors, are needed (Kunze, 2021).  

This dissertation study introduces a novel approach utilizing the Collaborative Model for 

Promoting Competence and Success (COMPASS) for Hope (C-HOPE) program. The C-HOPE 

program is an intervention designed for caregivers of children with autism, which aims to 

decrease child problem behavior, reduce parenting stress, and increase parenting sense of 

competency (Kuravackel et al., 2017). This program employs a coaching model, where trained 

interventionists collaborate with caregivers to teach evidence-based strategies and techniques for 

interacting with their child. C-HOPE has shown promise in improving parent and child 

outcomes, particularly in reducing parenting stress and enhancing parenting sense of competency 

of caregivers of children with autism (Kuravackel et al., 2017; McIntyre et al., 2021). 

While C-HOPE has demonstrated effectiveness in improving parent and child outcomes, 

it has not yet been utilized for caregivers of children on the ASD waitlist. In this study, I 

evaluated the potential efficacy of C-HOPE in improving caregiver outcomes and measure the 

acceptability of C-HOPE for caregivers of children on the ASD waiting list. The unique aspect of 

this study lies in its emphasis on assessing caregiver outcomes of those with children on the 

autism evaluation wait list, recognizing the pivotal role caregivers play in a child's life. Another 

unique aspect of the study is that the intervention is briefer and the modality is hybrid/online to 

increase accessibility during the waiting period.  

The current dissertation is guided by three theoretical frameworks: the ABC-X Model of 

Family Stress and Coping (McCubbin and Patterson, 1983), the Transactional Model of Stress 

3 

 
 
 
and Coping (Lazarus and Folkman, 1984), and Social Learning Theory (Bandura, 1977). The 

ABC-X model provides a comprehensive framework for understanding caregiver stress by 

considering caregiver stressors, available family resources, and caregiver perceptions of stressful 

events. This model emphasizes the importance of addressing both external stressors and internal 

resources in interventions and support programs for caregivers. The Transactional Model of 

Stress and Coping builds upon the ABC-X model and places a greater emphasis on cognitive 

appraisal, highlighting that caregivers' appraisals of stressful events are crucial determinants of 

their stress levels. This model underscores the interrelationships among caregiver self-efficacy, 

coping abilities, and behavior management strategies, all of which are central components of the 

C-HOPE intervention. Finally, Social Learning Theory emphasizes the role of observational 

learning and social interactions in shaping human behavior. This theory provides a basis for 

caregiver-to-caregiver coaching in consultation, where experienced caregivers model effective 

strategies and behaviors for newer caregivers, fostering a supportive environment and promoting 

better outcomes for both the caregiver and the child with ASD. These three theoretical 

frameworks collectively inform the approach taken in the current study to understand and 

mitigate caregiver stress in the context of supporting children with ASD. 

Overall, the aims of this dissertation study are to evaluate the efficacy of C-HOPE in 

reducing caregiver stress, increasing caregiver self-efficacy, increasing parent knowledge about 

parenting practices, and decreasing child behavior problems. Additionally, the study examined 

the acceptability of C-HOPE for caregivers who have children on the autism evaluation waitlist. 

It is the PIs hope that participation in C-HOPE can provide timely support for families 

navigating the complexities of ASD assessments, with the goal of decreasing their stress, 

4 

 
 
 
improving their self-efficacy as a caregiver, increasing their knowledge about behavioral 

principles, and decreasing challenging child behavior.  

The following research questions were examined: (1) Do caregivers, who are in the process 

of obtaining an autism diagnosis for their child and participate in the C-HOPE intervention, show 

a pre-post difference in caregiver stress immediately after undergoing the C-HOPE intervention 

as measured by the Parental Stress Index—Fourth Edition Short Form (PSI-4 SF; Abidin 2012)? 

(2) Do caregivers, who are in the process of obtaining an autism diagnosis for their child and 

participate in the C-HOPE intervention, show a pre-post difference in caregiver self-efficacy 

immediately after undergoing the C-HOPE intervention as measured by the Being a Parent Scale 

(BPS; Johnston and Mash 1989)? (3) Do caregivers, who are in the process of obtaining an 

autism diagnosis for their child and participate in the C-HOPE intervention, show a pre-post 

difference in parent knowledge about parent training and supportive strategies immediately after 

undergoing the C-HOPE intervention, as measured by the Parent Knowledge Questionnaire 

(PKQ; Dahiya et al., 2021)? (4) Do children of caregivers, who are in the process of obtaining an 

autism diagnosis for their child and participate in the C-HOPE intervention, show a pre-post 

difference in child behavior problems immediately after undergoing the C-HOPE intervention, as 

measured by the Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 1999)? and (5) 

How do families perceive the acceptability of the intervention, intervention appropriateness, and 

feasibility of the intervention, as measured by a post-intervention rating scale and focus group?  

Seven caregivers of children 5 to 12 years of age (M = 8.30; SD = 2.93) on a waiting list 

for an autism evaluation with behavioral concerns participated in the intervention. Children of 

the caregivers were from a community sample and had externalizing behavior at or above the at-

risk range (T-score of 60 or higher) as measured by the Eyberg Child Behavior Inventory (ECBI; 

5 

 
 
 
Eyberg and Pincus, 1999), and elevated scores (Raw score > 11) on the Social Communication 

Questionnaire (SCQ: Rutter et al., 2003) or elevated scores (Raw score > 3) on the Modified 

Checklist for Autism in Toddlers (M-CHAT; Robins et al., 2009). Before and after the 

intervention, caregivers completed measures of stress using the Parenting Stress Index – Fourth 

Edition (PSI-4 SF; Abidin, 2012), competence using the Being a Parent Scale (BPS; Johnston & 

Mash, 1989), parent knowledge of behavior strategies using the Parent Knowledge Questionnaire 

(PKQ; Dahiya et al., 2021), and child behavior challenges using the ECBI. At the end of the six-

week intervention, caregivers participated in a one-hour focus group to understand their insights 

about the parent training program and to learn more about its utility as a service while families 

waiting for the evaluation. Caregivers also completed measures of acceptability, feasibility, and 

intervention appropriateness.  

Results of the study provide promising initial support for C-HOPE as an intervention for 

caregivers of children awaiting an evaluation for autism. Participants reported reduced scores of 

stress, increased scores of self-efficacy and parent knowledge about behavior management, and 

reduced child behavior concerns from pre- to post-intervention. Additionally, participants found  

C-HOPE to be an acceptable intervention. Future research is needed to replicate these 

findings with a larger and more diverse sample to enhance generalizability. Further, the PI has a 

goal to implement C-HOPE for broader implementation in clinical and community-based 

systems that provide support for caregivers who are waiting for an evaluation for autism for their 

child. 

6 

 
 
 
LITERATURE REVIEW 

The aims of this dissertation study were to evaluate the effectiveness and acceptability of 

a parent training program called C-HOPE for caregivers who have a child on the waitlist for an 

autism spectrum disorder evaluation. The focus of the study was on reducing caregiving stress, 

increasing caregiver self-efficacy, increasing parent knowledge about behavior management, and 

reducing child behavior problems. The results of the study addresses a gap in the literature by 

evaluating the potential efficacy and acceptability of a parent training program that is 

individualized, multi-modal (pre-recorded modules, online-sessions, and in-person sessions), and 

aimed at giving caregivers the tools for behavior management while they wait for the evaluation.  

Overview of Autism Spectrum Disorder (ASD) 

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by 

persistent deficits in social communication and social interaction across multiple contexts, as 

well as restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric 

Association, 2013). Symptoms typically appear in early childhood and range from person to 

person. ASD affects social communication and social interactive behavior (American Psychiatric 

Association, 2013). Social communication in individuals with ASD may include delayed 

language development, difficulty with nonverbal communication (e.g., eye contact, facial 

expressions, gestures), difficulty with initiating and maintaining social relationships, and 

difficulty understanding social cues and norms. These challenges with social communication can 

lead to social isolation, misunderstandings, and difficulty with daily life activities (Mundy, 

2018). In addition to social communication and social interaction difficulties, individuals with 

ASD also have restrictive, repetitive behaviors, and interests (American Psychiatric Association, 

2013). Restricted, repetitive behaviors and interests in individuals with ASD may include 

7 

 
 
 
repetitive movements or gestures (e.g., hand flapping, rocking), insistence on sameness or 

routines, intense interests in specific topics or objects, and sensory sensitivities or preferences 

(American Psychiatric Association, 2013). These behaviors and interests can interfere with daily 

life activities and social relationships (Kanne et al., 2011).  

The most recent statistic states that roughly one in 36 children has been identified with an 

ASD (Maenner, 2023). This represents an increase in the prevalence of ASD identifications 

compared to previous years. In 2016, the Centers for Disease Control (CDC) reported that 1 in 

54 children were diagnosed with ASD, and in 2006, the prevalence was 1 in 110 children (CDC, 

2006; Maenner et al., 2020). This increase could be due to better awareness and earlier 

identification of ASD, as well as changes in diagnostic criteria and increased access to services 

(Zuckerman et al., 2017; Zwaigenbaum et al., 2015). These numbers also suggest that more 

children are being evaluated for ASD each year. This has led to a growing waitlist for ASD 

assessments (Gordon-Lipkin et al., 2016).  

Caregivers typically experience a delay between their initial help-seeking and the actual 

diagnosis. For instance, research by Crane et al. (2016) indicates that caregivers seeking an ASD 

diagnosis for their child can anticipate waiting 3.4 to 5 years before receiving confirmation. In a 

recent large-scale study, Chen et al. (2023) used real-world healthcare data from a national 

research network to assess the duration between developmental screening and an official autism 

diagnosis. Their analysis looked at electronic health records of children with autism across 

multiple US healthcare organizations (HCOs). The study revealed a notable delay, with the 

average diagnostic timeline extending to 26.9 months from the initial developmental screening. 

8 

 
 
 
 
 
 
Models of Caregiver Stress, Efficacy, and Social Learning 

The current study is guided by the ABC-X Model of Family Stress and Coping 

(McCubbin and Patterson, 1983), The Transactional Model of Stress and Coping (Lazarus and 

Folkman, 1984), and Social Learning Theory (Bandura, 1977).  

ABC-X Model of Family Stress and Coping 

The ABC-X model was first introduced by McCubbin and Patterson (1983) as a 

framework for analyzing the factors that determine the relationship between stressful events and 

crises within families (Rosino et al., 2013). This model, which is a precursor to the next 

discussed theory, identifies three main variables that play a role in determining caregiver stress 

levels: (A) caregiver stressor (which refers to specific stressors or events that a caregiver may 

experience), (B) available family resources (including material resources and social support, 

etc.), and (C) caregiver perceptions of the stressful situation of event (i.e., their cognitive 

appraisal of the stressful event). The three variables result in variable X which is the amount of 

crisis that occurs as an outcome of the stressor or stressful event and its interaction with the 

family. According to the Double ABC-X model, heightened caregiver stress is typically linked to 

at least one of these three categories, although it is not uncommon for stress to be related to all 

three (see Figure 1). 

This model provides a valuable framework for understanding the complex and 

multifaceted nature of caregiver stress, highlighting the importance of considering both external 

stressors and internal resources when examining the impact of stress on caregivers. By 

recognizing the various factors that contribute to caregiver stress, interventions, and support 

programs can be developed to address these factors and promote greater resilience and well-

being among caregivers and their families. 

9 

 
 
 
 
In the context of C-HOPE, the consultant engages in a collaborative process with the 

consultee to explore the risk and protective factors within the consultee's family unit. Through 

this interaction, the consultee uncovers pathways to mitigate caregiver stress by harnessing the 

strengths within the family. This approach not only empowers the consultee but can also foster 

an environment of support and growth for the consultee. By using this model, the consultant 

proactively works with the caregiver to analyze the child’s personal and environmental 

challenges and personal and environmental supports.  The consultant then develops targeted 

strategies to enhance these supports by addressing the child’s behavior and teaching the 

caregiver strategies to manage their stress.  

Figure 1 

ABC-X Model of Family Stress and Coping (McCubbin and Patterson, 1983) 

Stressor Event 

Resources 

Perception 

Crisis 

Note. This model was adapted from “Theory Series: ABC-X Model of Family Stress” by Allis on 

Tidwell from https://militaryreach.auburn.edu/FamilyStoryDetails?resourceid=f58dcb51-bb9e-

47a4-a72e-db8b99c18b41  

10 

 
 
 
 
 
 
 
 
 
 
 
 
The Transactional Model of Stress and Coping 

The transactional model introduced by Lazarus and Folkman (1984) is the primary 

guiding model for the current work. This model builds upon the Double ABC-X model and 

places a greater emphasis on cognitive appraisal. According to this model, caregivers' appraisals 

of stressful events are key determinants of their stress levels. According to this theory, there are 

specific patterns of primary and secondary appraisals that lead to different kinds of stress: harm, 

threat, and challenge. Harm refers to psychological damage or loss that has already occurred, 

while threat is the anticipation of imminent harm, and the challenge arises from demands that a 

person feels confident about mastering. These different types of psychological stress are 

embedded in specific types of emotional reactions, highlighting the close relationship between 

the fields of stress and emotions (see Figure 2). 

According to this model, caregivers who doubt their ability to manage challenging child 

behaviors or cope with stressors may be more susceptible to experiencing stress. On the other 

hand, caregivers who have previously succeeded in managing challenging behaviors and coping 

with stressors, and thus feel more confident in their abilities, may be less likely to feel stressed. 

The transactional model highlights the interrelationships among caregiver self-efficacy, coping 

abilities, and behavior management strategies, which are fundamental components taught in C-

HOPE. In the transactional model, there are primary appraisals, including perceived 

susceptibility to stressors and motivation to cope. There are also secondary appraisals of stress, 

including perceived control over the outcomes and control over their emotions. By participating 

in C-HOPE, caregivers can address their perceived appraisal of behavioral challenges and can 

enhance their confidence in supporting their child, thereby reducing stress levels (Kurvackel et 

al., 2017).  

11 

 
 
 
Figure 2 

Transactional Model of Stress and Coping (Lazarus & Folkman, 1984)  

Stressors 

Internal or external demands 

Primary 

Appraisal 

Secondary 

Coping Resources  

Coping Responses  

Personal attributed 

Emotion- or problem-focused coping 

Long-term Outcomes 

Short-term Outcomes 

Physical health 

Mental health 

Relaxation  

Mood 

Note. This model was adapted from Margaret, K., Ngigi, S., & Mutisya, S. (2018). Sources of 

occupational stress and coping strategies among teachers in borstal institutions in 

Kenya. Edelweiss: Psychiatry Open Access, 2(1), 18-21. 

Social Learning Theory 

 The final theory that guides this work is Social Learning Theory (SLT; Bandura, 1977). 

SLT emphasizes the role of social interactions and observational learning in shaping human 

behavior. SLT proposes a set of processes for how behavior is learned (Akters and Jennings, 

2015). The first process is attention, which emphasizes the degree to which the individual notices 

others’ behavior. The second process is retention, which refers to how well the individual 

12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
remembers the observed behavior. The third process is reproduction, which refers to the capacity 

(e.g., skills) and ability to act out the behavior. Finally, motivation refers to the extent to which 

the individual is driven to imitate the observed behavior. 

According to this theory, individuals can learn and adopt new behaviors by observing 

others, such as peers and/or family members, by imitating their actions. SLT also highlights the 

role of reinforcement and punishment in shaping behavior, suggesting that individuals are more 

likely to adopt behaviors that are rewarded and less likely to engage in behaviors that are 

punished. In fact, C-HOPE was built upon the principles of SLT, recognizing that changes in an 

individual can be shaped by an individual's environment, behavior, and cognition. For instance, 

the behavior of a consultee in C-HOPE can be markedly affected by factors such as their self-

efficacy and level of stress. 

C-HOPE is directly informed by SLT in both its structure and concept, as it facilitates 

caregiver-to-caregiver coaching within a supportive cohort model. This design allows caregivers 

to observe, practice, and reinforce effective parenting strategies in a structed setting. The 

attention process is embedded in the intervention by creating opportunities for caregivers to 

watch and engage with an experienced clinician modeling behavioral strategies. The retention 

process is supported through hands-on practice, where caregivers actively implement strategies 

with feedback from peers and facilitators. Finally, motivation is fostered by creating an 

environment in which caregivers receive positive reinforcement, encouragement, and social 

validation from both the clinician and peer caregivers, increasing their confidence and likelihood 

of sustained behavior change. 

Furthermore, SLT underscores the importance of reinforcement in shaping behavior, 

which is a core component of C-HOPE. Caregivers receive continuous feedback and 

13 

 
 
 
encouragement from both peers and clinician, reinforcing their use of evidence-based 

interventions. Over the course of the program, caregivers practice these strategies, which 

increase their confidence and competence with using them, enabling them to more effectively 

reinforce desired behaviors in their children. By embedding these SLT principles, C-HOPE not 

only enhances caregiver self-efficacy but also reduces caregiver stress and improves child 

outcomes.  

Caregiver Stress 

 Caregivers of children who are showing early signs of ASD and those who are on the 

ASD waiting list for an evaluation may experience a range of difficult emotions and stressors. 

Waiting for a diagnosis or assessment can be a time of uncertainty, fear, and anxiety as 

caregivers try to navigate an unfamiliar and complex system (Graungaard & Skov, 2007). They 

may also experience a sense of uncertainty due to the lack of control over the process and the 

unknown outcome (Rivard et al., 2014). Further, caregivers of children with ASD often face 

unique challenges trying to navigate an evaluation, including wait times, insurance barriers, un-

coordinated referral processes, and multi-day evaluation sessions, which can lead to them feeling 

confused, disempowered, and overwhelmed (Zukerman et al., 2015; Mulligan et al., 2012). 

According to Lazarus (1966), stress is the psychological condition that arises when a 

person perceives situational demands as exceeding their ability to cope. Caregiving stress is one 

particular form of stress that results from the caregiving role and its associated challenges 

(Deater-Deckard, 1998, 2004). Caregiving stress and child externalizing behavior problems are 

closely related across child development (Neece et al., 2012). This means that greater caregiving 

stress can predict greater child externalizing problems and vice versa. Furthermore, greater 

caregiving stress can result in higher rates of mental health problems and psychopathology 

14 

 
 
 
(Deater-Decker, 2004; Salomone et al., 2018). Research has also suggested that caring for a child 

with a disability is strongly related to higher levels of caregiving stress (Deater-Deckard, 2004; 

Hayes & Watson, 2013; Tervo, 2012). Caregivers of children with ASD report high levels of 

caregiving stress (Hayes and Watson, 2013), such as due to the demands of caring for a child 

with ASD (e.g., Hodge et a., 2011), behavioral and emotional challenges associated with ASD 

(e.g., Benson & Karloff, 2009), adaptive level of functioning (e.g., Hall & Graff, 2011), social 

communication deficits and restricted and repetitive behaviors (Hayes & Watson, 2015), and 

executive functioning deficits (Epstein et al., 2008). Additionally, caregivers of children with 

ASD diagnosis report higher levels of caregiving stress compared to caregivers of children with 

other disabilities and caregivers of typically developing children (Hayes & Watson, 2013). 

Caregiving stress can also influence the effectiveness of interventions for children with 

ASD. Osborne et al. (2008) found that higher caregiving stress was associated with reduced 

effectiveness of early interventions for these children. When caregivers are under substantial 

stress, maintaining consistent behavior modeling and reinforcement for their child might become 

challenging, which could lead to an escalation in the child’s behavior difficulties, initiating a 

cycle where caregiver stress and child challenging behavior reinforce each other.  

Research has found that including stress reduction (e.g., mindfulness and coping skills 

training) as part of parenting programs for caregivers who have a child with autism not only 

reduces caregiver stress but also reduces child behavior (e.g., Cachia et al., 2016). This 

highlights the importance of addressing caregiver stress as part of interventions aimed at 

improving outcomes for children with ASD. However, before caregivers can seek intervention 

for their child with ASD, they must first receive an evaluation.  

15 

 
 
 
 
While there is a large amount of literature on caregiver stress of children with diagnosed 

ASD, few studies have focused on the parenting stress of caregivers who have children with 

concerns consistent with ASD but who do not yet have a diagnosis. DesChamps (2020) points 

out that this is an important area for future research, as understanding the experiences and 

stressors of caregivers in these situations can inform the development of appropriate 

interventions and support services for caregivers before formal diagnostic evaluations. 

Caregivers face the daunting task of navigating a complex and frequently demanding service 

system that starts before the diagnosis and persists throughout their child's life (Smith et al., 

2020). 

Caregiver Self-Efficacy  

Self-efficacy is a key component of caregiving (Guimond et al., 2008) Caregiver self-

efficacy refers to the belief a caregiver has in their ability to effectively manage and cope with 

the responsibilities and challenges of caregiving (Coleman & Karraker, 1998). Incorporating 

social learning theory, Bandura (1977) defined self-efficacy as a combination of factors, 

including personal achievement, observing the experiences of others, receiving affirmation from 

others, and using physiological states to evaluate one's capabilities. Caregiver self-efficacy, 

therefore, refers to caregivers’ beliefs and perceptions of their own competence in fulfilling their 

roles and meeting the demands of being caregivers.   

Self- efficacy is linked to many aspects of psychological functioning. Perceived caregiver 

self-efficacy has been shown to be related to caregiver stress (Tang et al., 2015), with high levels 

of caregiver efficacy associated with lower levels of caregiver stress (DesChamps et al., 2020). 

Across maternal and paternal self-efficacy, maternal self-efficacy has been associated with 

positive caregiving outcomes, such as agency and lower feelings of guilt in mothers of children 

16 

 
 
 
with autism (Kuhn & Carter, 2006). Regarding paternal self-efficacy, higher use of strategies to 

cope with their child's behavior has been shown to boost fathers' feelings of self-efficacy 

(Rudelli et al., 2021). Further, higher levels of self-efficacy in fathers of children with autism are 

associated with lower stress levels and lower incidences of depression and anxiety (Garcia et al., 

2016a). Taken broadly, low self-efficacy predicts depression, lack of motivation, and low self-

esteem in caregivers of children with and without developmental disabilities (Bandura, 1982).  

Increased levels of caregiver self-efficacy have been associated with decreased parental 

anxiety, depression, and child behavioral problems (Hastings & Brown, 2002; Kuhn & Carter, 

2006; Weiss et al., 2012). For instance, Hastings and Brown (2002) found that caregiver self-

efficacy acted as a mediator between child behavior problems and maternal anxiety and 

depression, while for fathers, caregiver self-efficacy moderated the relationship between child 

behavior problems and paternal anxiety. Coleman and Karraker (1997) suggest that when 

caregivers possess a sense of knowledge and confidence in their caregiving role, it leads to 

higher levels of caregiver self-efficacy, which in turn can positively influence their overall 

competence (Sanders, 2003). 

Self-efficacy is also impacted by waiting for evaluations. In the context of wait lists, 

Murphy & Harrison (2022) found that securing a space on the waiting list for an autism 

evaluation increased caregiver self-efficacy as it confirmed the caregivers' validity of their 

concerns about their child’s development. Consequently, when caregivers on the ASD waitlist 

receive parent training, it can be hypothesized that it may not only equip them with practical 

skills, but it could increase self-efficacy. 

17 

 
 
 
 
 
Caregiver Knowledge 

Caregiver knowledge about how to manage behaviors has been shown to increase 

caregiver self-efficacy (Keen et al., 2010; Kurzrok et al., 2021) and reduce caregiver stress (Keen 

et al., 2010). Parent training programs focused on increasing caregiver knowledge about children 

with ASD have demonstrated effectiveness in increasing parental knowledge, thereby increasing 

self-efficacy and knowledge about evidence-based behavior strategies (Hardan et al., 2015; 

Hassenfeldt et al., 2015). Around the time of evaluation, and often following diagnosis, 

caregivers express wanting practical tools to manage their child’s behavior (Colombet et al., 

2023). Participation in parent training focused on increasing caregiver knowledge has also 

demonstrated effectiveness in reducing child behavior problems and improving caregiver 

competence while reducing parental stress (Ladarola et al., 2018).  

Overview of Assessment Procedures and Services for ASD 

The assessment of ASD is a complex process that involves several steps. The first step is 

to have a suspicion that someone may have ASD based on observed behaviors and 

developmental milestones. Once a suspicion arises, the person or their caregiver can seek an 

evaluation from a professional, such as a psychologist or pediatrician, who specializes in the 

assessment of ASD. The evaluation involves a comprehensive assessment of the individual's 

social, communication, behavioral, cognitive, adaptive, medical, and speech development. After 

the evaluation, a diagnosis of ASD may be determined (Huerta & Lord, 2012). Once diagnosed, 

the individual and their caregiver can seek services that are appropriate for their age and level of 

support needs. For example, for young children with ASD, early intervention services may be 

recommended, which can include speech and language, occupational, and behavioral therapies.  

18 

 
 
 
 
 
 
Initial Suspicion of ASD 

The initial suspicion of an ASD may vary depending on the age of the individual and the 

severity of the presenting symptoms. In general, the suspicion of an ASD by a caregiver may 

arise when a child exhibits persistent deficits in social communication and social interaction, as 

well as restricted and repetitive patterns of behavior, interests, or activities (Wiggins et al., 

2012). For infants and toddlers, the suspicion of an ASD may arise if they do not respond to their 

name, avoid eye contact, have delayed language development, and exhibit repetitive behaviors 

such as hand flapping or rocking (Zwaigenbaum et al., 2015). Caregivers may also notice that 

their child does not show interest in playing with others, has difficulty understanding social cues 

and norms, and displays an intense interest in specific topics or objects (Zablotsky et al., 2015). 

For older children and adults, the suspicion of an ASD may arise if they have difficulty making 

and maintaining friendships, struggle with social communication, exhibit inflexible thinking or 

routines, and have difficulty adapting to changes in routine (Levy et al., 2020). They may also 

have difficulty understanding nonverbal communication, such as facial expressions and body 

language, and may have sensory sensitivities or preferences. 

Pathways to Services  

The two primary pathways to services for children with ASD are in clinical and school 

settings. Both pathways involve assessment procedures to meet criteria for ASD, but there are 

some differences between the two in terms of diagnoses vs eligibility, available services, and 

personnel involved. It is important to note before delving into the pathways that the field has not 

settled on a specific set of tools or processes for diagnosing ASD (Kanne & Bishop, 2021); 

however, there are gold standard assessments that clinicians commonly use (Huerta & Lord, 

2012). As such, the processes for diagnosing ASD can be different for each individual.  

19 

 
 
 
The first pathway to services for children with ASD is through clinical evaluations. 

Through this process, clinicians employ a series of evaluation procedures to make a diagnosis 

based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The 

DSM-5 is a widely recognized diagnostic tool used by healthcare professionals to diagnose ASD 

and other mental health disorders.  

The DSM-5 provides specific diagnostic criteria for ASD, which include deficits in social 

communication and social interaction, as well as the presence of restricted, repetitive patterns of 

behavior, interests, or activities. The criteria specify that these symptoms must be present in 

early childhood but may not fully manifest until later developmental periods. The DSM-5 criteria 

are designed to ensure that individuals who are diagnosed with ASD meet a standardized set of 

diagnostic criteria, which can help to ensure consistency and accuracy in diagnosis across 

healthcare providers.  

The process of diagnosing an ASD in a clinic can be lengthy and complex and requires a 

thorough evaluation by highly skilled professionals. ASD evaluations are commonly initiated 

either by concerned caregivers reaching out to healthcare providers for assessments or through a 

referral from a healthcare provider, such as a psychologist or pediatrician (Johnson et al., 2007). 

Clinical assessments typically involve a range of gold-standard assessment tools and tests, 

including the widely used Autism Diagnostic Observation Schedule- Second Edition (ADOS-2; 

Lord et al., 2012) and then Autism Diagnostic Interview-Revised (ADI-R; Lord et al., 1994) to 

provide further information on the child's behavior and development. The ADOS-2 and the ADI-

R are used for determining the criteria of autism, while the adaptive behavior scales are used to 

characterize the level of support needed. Tools such as the Vineland-Third Edition (Vineland-3; 

Sparrow et al., 2016) are used to assess the individual's adaptive communication, socialization, 

20 

 
 
 
and behavior skills. In addition to these assessments, parents or caregivers are often interviewed 

using gold-standard assessment tools like the Additional recommendations for comprehensive 

autism evaluations include a record review, observation of the child, an interview with the 

child’s caregivers and/or family, assessment for the core features of autism, standardized 

cognitive, developmental, language, and behavior assessment, as well as consideration of 

differential diagnoses and co-occurring conditions, and the consideration of developmental 

factors throughout the diagnostic process (Huerta & Lord, 2015). These best practices are 

generally implemented using a multidisciplinary approach (Huerta & Lord, 2015).  

While the diagnostic process is critical in identifying ASD and ensuring appropriate 

interventions and services are provided, it can also be challenging. Diagnostic evaluations can 

take several days to complete, and there is often a shortage of trained professionals available to 

conduct these assessments (Fenikilé et al., 2015). This can result in long wait times for families 

seeking a diagnosis, as well as difficulties in accessing services and interventions in a timely 

manner. Moreover, the diagnostic process can be emotionally and mentally taxing for families, 

who may experience anxiety and uncertainty as they navigate the evaluation process (Resch et 

al., 2010).  

The second route to receiving services is through school-based services. In 1990, the 

United States Congress amended the federal special education law (now called the Individuals 

with Disabilities Education Improvement Act) to make autism a category of education disability. 

Under the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA), students in 

schools undergo evaluations for mental health disorders or disabilities. IDEIA ensures access to 

appropriate public education for students with disabilities. IDEIA guides the way states provide 

and implement statewide, comprehensive, multidisciplinary systems and services for eligible 

21 

 
 
 
 
children. IDEIA established the process of identifying children who have disabilities, and 

presents broad groups of disabilities that warrant “alternative, specialized services guaranteed by 

law” (Wodrich et al., 2008). In schools, children are not diagnosed with mental health disorders 

as outlined in the DSM-5. Instead, they meet eligibility for thirteen different categories of 

disabilities. However, within public school systems, children who have been clinically diagnosed 

with ASD and are found through their school district to experience academic difficulties 

attributable to their diagnosis, are also identified as having autism through IDEIA criteria 

(Pennington et al., 2014).  

Federal special education law addresses evaluation procedures for determining whether a 

student is diagnosed as having a disability, including autism: “The child is assessed in all areas 

related to the suspected disability, including, if appropriate, health, vision, hearing, social and 

emotional status, general intelligence, academic performance, communicative status, and motor 

abilities” (IDEIA, Sec. 300. 304 (c), 2004). However, each state determines evaluation 

procedures, and these may be further modified by individual school districts. So, evaluation 

procedures can be different from state to state.  

According to Wilkinson (2017), multiple components should be included in a school-

based assessment. These components are record review, developmental and medical history, 

medical screening and/or evaluation, caregiver interview, caregiver/teacher ratings of social 

competence, cognitive/intellectual assessment, academic assessment, communication and 

language assessment, assessment of restricted and repetitive behavior (RRB), and adaptive 

behavior assessment (California Department of Developmental Services, 2002; Campbell et al., 

2014; Johnson et al., 2007; Klin et al., 2005; National Research Council, 2001; Ozonoff et al., 

2007; Payakachat et al., 2012). However, the assessment process will vary and depend on the 

22 

 
 
 
child’s age, history, referral questions, and any previous evaluations and assessments 

(Wilkinson, 2017), as well as available school resources. In schools, evaluations and assessments 

are oriented to educational services geared toward whether the disability interferes with 

academic performance (Huerta & Lord, 2012).  

Limitations in the Access to Support  

Despite the outlined pathways to evaluations, there remains a large waitlist. There are 

multiple limitations that families face when they seek both assessments. Among these 

challenges, three prominent challenges include the prolonged waiting times for evaluations. 

barriers faced by residents in rural communities, and economic disadvantages. 

Waiting Period for ASD Evaluation 

Families often face a substantial gap in services from the initial suspicion of ASD in their 

child to the actual evaluation process (Craise et al., 2016). The wait time is commonly assessed 

through practitioner and caregiver reports. For instance, a recent survey of pediatricians in 

Canada reported a median wait time of 7 months (Penner et al., 2018). In the United States, a 

study reported that the mean age of ASD diagnosis was 4.4 years, with an average delay of 

receiving the diagnoses being around 2.2 years, meaning children typically wait 2.2 years for a 

diagnosis (Zuckerman et al., 2017). Caregivers reported delays ranging from 12 to 55 months in 

a scoping review by Makino et al. (2019). Research by Crane et al. (2016) suggests that 

caregivers seeking an ASD diagnosis can expect to wait approximately 3.4 to 5 years for 

confirmation. The most recent statistic from a large-scale study that used real-world healthcare 

data found that children with autism wait approximately 21 to 26.9 months for an evaluation 

(Chen et al., 2023). While there is considerable variability in the duration of evaluation waiting 

times, the consistent theme is the significant waiting period that families undergo.  

23 

 
 
 
 
Rural Service Disparity 

Families who live in rural communities often lack access to evidence-based services for 

evaluations, home and school support, parent-related services, and additional services such as 

occupational therapy and speech therapy (Mello et al., 2016). Of the available services, families 

report that they are not effective (Antezena et al., 2017). In particular, Mello et al. (2016) found 

that not only are behavioral supports not widely spread to rural areas but they are less effective 

than non-rural areas (Mello et al., 2016). This may be due to reduced access to resources, 

challenges in providing consistent interventions due to distances traveling to and from the 

centers, and a scarcity of competent clinicians. Additionally, many families have reported that 

they lack access to specialized services that work with children who have ASD (Hendryx, 2008; 

Knapcyzk et al., 2001; Murphy & Ruble, 2012). For example, a recent study conducted by 

Drahota et al. (2020) found that families living in rural areas had fewer available ASD providers 

compared to those in suburban and urban neighborhoods, highlighting the presence of service 

deserts in these areas. 

Economic Disadvantage Disparity 

Socioeconomic disparities in access to interventions for ASD is well-documented in the 

literature (Singh & Bunyak, 2018). Neighborhoods with higher levels of socioeconomic 

disadvantage tend to have fewer ASD providers available (Drahota et al., 2020). The unequal 

access to quality autism care is influenced by various social determinants of health, such as 

family and neighborhood-level socioeconomic status and minority racial and ethnic status 

(Durkin et al., 2010; Liptak et al., 2008; Pickard & Ingersoll, 2016). Dallman et al. (2020) 

conducted a systematic review and found that many individuals from economically 

24 

 
 
 
disadvantaged backgrounds stop receiving services once they age out of school as school was 

their primary mode of getting services.  

Race and Ethnicity Disparity 

Racial and ethnic minority families often utilize fewer early intervention and ASD-

specific services (Broder-Fingert et al., 2013; Magaña et al., 2013; Pickard & Ingersoll, 2016) 

and encounter more barriers to accessing services (Stahmer et al., 2019). These disparities in 

service access and use are due to many factors, including the availability of culturally sensitive 

services (Arday, 2018), stigma associated with mental health in their communities, unequal 

access to quality healthcare, and mistrust of healthcare systems (McGuire & Miranda, 2008). 

Additional barriers include cultural and linguistic considerations in treatment, financial 

pressures, and knowledge about services (Wallace-Watkin et al., 2023). The disparities in access 

to quality care highlight the need for further efforts to address the social determinants of health 

that contribute to these inequalities and to promote equitable access to evidence-based 

interventions for all children with ASD, regardless of their socioeconomic or racial and ethnic 

background. 

A Need for Intervention to Support Caregivers on the ASD Waiting List 

The current body of literature regarding ASD caregiver support has primarily focused on 

providing interventions for families with a child who has already been diagnosed with ASD. 

While numerous interventions are developed for caregivers with a child already diagnosed with 

ASD, there is a notable scarcity of interventions addressing caregivers on the waitlist who do not 

yet have a diagnosed child. For example, many caregiver-focused interventions aim to support 

children’s social communication. Interventions such as the Early Start Denver Model (ESDM; 

Dawson et al., 2010), Milieu Training (Kaiser & Gray, 1993), Joint Attention Symbolic Play, 

25 

 
 
 
Engagement, and Regulation (JASPER; Kasari et al., 2006), and More Than Words—Hanen 

Model; Weitzman, 2013) are widely utilized to support child social communication and 

behavior. Moreover, most caregiver-mediated interventions developed to date have been 

developed with children with autism (Yu et al., 2019).  

A large body of evidence has been published in the last 15 years that used randomized 

clinical trials to demonstrate the positive impacts on child outcomes from parent-mediated 

interventions for children with ASD (e.g., Nevill et al., 2018; Cheng et al., 2023). For example, 

Treatment and Education of Autistic and Related Communication Handicapped Children 

(TEACH; Welterlin et al., 2012), Pivotal Response Training (PRT; Hardan, 2014), and Social 

Communication, Emotional Regulation, and Transactional Supports (SCERTS; Wetherby et al., 

2014) are all parent-mediated interventions that demonstrate positive effects for children with 

autism. Yet, caregivers often face difficulties and stressors before their child receives a 

diagnosis. For example, prior work has highlighted that caregivers often express concerns about 

their child’s behavior before the median age of ASD diagnoses [i.e., 4.33 years (Baio et al., 

2018)]. Therefore, services for families with children who are on the ASD evaluation waiting list 

are also needed.  

Access to these programs is often dependent on already having a clinical autism 

diagnosis, meaning families who are still waiting for an evaluation often cannot access them. 

This barrier poses a significant challenge for families amid the evaluation process, as they are 

often unable to receive these evidence-based resources until a formal diagnosis is obtained. 

Consequently, this gap in support can exacerbate the existing stress experienced by caregivers 

during the waiting period, further underscoring the need for interventions that address the unique 

needs of caregivers with children on the autism evaluation waitlist.  

26 

 
 
 
Current Interim Services Used in the Field  

Even with the consensus among researchers and clinicians about the importance of 

intervention and access to services, there is limited research in the area of interventions for those 

on the autism evaluation wait list (Roberts et al., 2016). To date, there are a few programs and 

interventions aimed at supporting families on the ASD waiting list.  

Occupational Performance Coaching (OCP). One intervention that has been used with 

caregivers of children on the ASD waiting list is Occupational Performance Coaching (OPC). 

OPC is an occupation-informed coaching intervention designed to address the self-identified 

goals of caregivers of children with autism (Graham et al., 2009; Graham et al., 2020). After 

picking the goals, caregivers learn strategies and are coached to use the strategies with their 

child. In a recent pilot feasibility study, Bernie et al. (2021) studied the effectiveness of OPC 

with 16 caregivers and their children waiting for an evaluation for autism. They conducted a 

randomized controlled trial, assigning participants to one of three conditions: (1) face-to-face 

coaching (FTF) using OPC, (2) videoconference coaching (VC) using OPC, or (3) usual care.  

The primary outcome measures included pre- and post-assessments of goal attainment 

using the Canadian Occupational Performance Measure (COPM; Law et al., 2017). In the 

intervention groups (both FTF and VC), 75% of participants (6 out of 8) achieved an average 

improvement of two or more points on the performance and satisfaction scales on the COPM. In 

contrast, only 25% of participants (1 out of 4) in the usual-care group showed a similar 

improvement. Additionally, the study examined secondary measures such as the Vineland 

Adaptive Behavior Scales (VABS-3; Sparrow et al., 2016), Social Responsiveness Scale (SRS-2; 

Constantino & Gruber, 2012), Beech Family Quality of Life Scale (FQOL; Park et al., 2003), 

and the shorter form Parenting Stress Index (PSI; Abidin, 1990). Families in the VC group 

27 

 
 
 
 
reported a decrease in parenting stress, while no significant decrease was observed in the 

treatment-as-usual group. Findings on the VABS-3 and SRS-2 were variable.  

Telehealth Coaching Intervention. Kunze et al. (2021) studied the effectiveness of 

telehealth coaching with five caregivers who received guidance for applying early intervention 

strategies to target interfering higher-order restrictive and repetitive behaviors and interests 

(RRBIs). The coaching incorporated four evidence-based applied behavior analytic strategies, 

including modeling, prompting, differential reinforcement of appropriate behaviors, and response 

interruption and redirection. The aims of the study had two main objectives. First, it aimed to 

investigate the relationship between the implementation of a caregiver education and coaching 

program and the increased utilization of targeted caregiver strategies, while also evaluating the 

acceptability and feasibility of these strategies. Second, the study sought to assess the impact of 

the intervention package on child inflexibility, specifically RRBIs.  

The results of the study indicated that each of the five caregivers increased their 

utilization of intervention strategies during the intervention phase, with an average usage of 

approximately 13 or more strategies. Commonly employed strategies included modeling and 

prompting, while contingent reinforcement was identified as the most frequently missed strategy. 

Regarding the second aim, all children demonstrated a reduction in RRBIs following the 

intervention. These findings emphasize the value of combining caregiver education about 

evidence-based strategies and coaching to support their implementation. These findings also 

highlight that structured coaching can enhance caregivers' fidelity in applying evidence-based 

interventions. Additionally, this study targeted one behavior (i.e., RRBIs), which reinforces the 

importance of targeted specific child behaviors alongside caregiver education to maximize 

intervention effectiveness.  

28 

 
 
 
Caregiver Support Groups. Caregiver support groups offer an additional avenue for 

caregivers to seek assistance while their child is on the autism evaluation wait list (Mandell & 

Salzer, 2007). Many caregivers express that support groups provide valuable support by 

connecting them with others in similar situations and equipping them with strategies to aid their 

children (Mandell & Salzer, 2007). Notably, research suggests that online support groups can be 

just as effective as in-person support groups (Clifford & Minnes, 2012). However, the 

availability of support groups specifically tailored for families on the autism evaluation wait list 

remains limited. 

A single qualitative study investigating caregiver support groups for caregivers of 

children on the autism evaluation wait list was identified (Conolly & Gersch, 2013). In this 

study, five caregivers participated in a caregiver support group, with each session lasting two and 

a half hours and occurring once a week for four weeks. The sessions covered various topics, 

including an introduction to ASD, evaluations, services, communication skills (both typical and 

atypical), behavior management, and emotional well-being within the family.  

A thematic analysis was conducted to analyze the data and to extract themes from the 

support groups. One prominent theme identified was the concept of a "journey," where 

participants described their experiences as being on a path and their desire for guidance from 

professionals who could show them the way and provide insights into potential outcomes. 

Another theme was the notion of "waiting," with participants expressing the difficulties and 

frustrations associated with the waiting period. They described feeling stuck in a state of limbo 

and perceived a loss of valuable intervention time. However, in hindsight, some parents noted 

that despite the delays, their children continued to grow and develop, suggesting that early 

behavioral support still had a positive impact. Broadly, the study's findings underscore that short-

29 

 
 
 
term caregiver support groups can help fulfill caregiver needs while they are on the waiting list 

for an assessment, offering education and information about autism, behavior, as well as peer-to-

peer support (Conolly & Gersch, 2013).  

Caregiver Training. Caregiver training is another avenue that families can participate in 

as it can provide a meaningful avenue for evidence-based interventions. Caregiver training or 

caregiver-implemented interventions involve professionals teaching and coaching caregivers to 

acquire new skills, which are then applied to their children (Akamoglu & Meadan, 2018). Both 

children and their caregivers can benefit from caregiver-implemented interventions (Cheng et al., 

2023). There are many positive outcomes of caregiver training for autism (Hume et al., 2021). 

Caregiver training programs can increase caregiver's sense of competence (Deb et al., 2020) and 

decrease caregiver stress (Ladarola et al., 2018). Concurrently, children with autism enrolled in 

these programs have shown improvements in outcomes such as their behavior (Dyches et al., 

2018; Nevill et al., 2018) and spontaneous imitation (Wainer & Ingersoll, 2015).  

The inclusion of caregiver training as a service recognizes the pivotal role that caregivers 

play in intervening in their children's development. By equipping caregivers with the tools 

necessary to provide evidence-based care, these programs can empower caregivers to actively 

contribute to positive outcomes for their child. As caregivers lessen their stress, gain confidence, 

and learn skills, they can become better equipped to address the unique challenges that arise in 

caring for a child with ASD (Jang et al., 2012). Simultaneously, the positive impact of caregiver 

training extends to children themselves, as evidenced by improvements in their behavior and 

overall functioning (Factor et al., 2019). 

Telehealth Caregiver Training. Telehealth and face-to-face interventions often yield 

similar outcomes across various domains of healthcare (Barak et al., 2008). This includes fields 

30 

 
 
 
such as mental health, where telehealth has proven to be a viable and cost-effective alternative to 

traditional in-person therapy for families with ASD (Hao et al., 2021). For example, Hao and 

colleagues (2021) studied a parent training program, called Project Skills and Knowledge of 

Intervention for Language Learning Success (SKILLS) and found no significant differences in 

the telehealth versus in-person modality. Additionally, Myers et al. (2007) found that telehealth 

services for children with developmental disabilities were not only equivalent in effectiveness 

but also resulted in fewer missed appointments and reduced travel costs for families. 

Furthermore, studies conducted by Slone et al. (2012) have underscored the economic 

advantages of telehealth. By eliminating the need for physical office space and reducing 

transportation expenses, telehealth interventions have the potential to significantly reduce overall 

costs for both service providers and clients. These cost savings can make healthcare more 

accessible and affordable, particularly for individuals in underserved or rural areas.  

Telehealth services have increased the delivery of individualized care by extending their 

reach to diverse geographic areas while ensuring the delivery of standardized evidence-based 

interventions with high fidelity (Wainer & Ingersoll, 2015). For example, Nefdt et al. (2010) 

found that caregivers were able to learn and implement pivotal response training (PRT) virtually 

with high fidelity. Recent evidence further support the efficacy of telehealth as a delivery method 

for behavioral programs, with caregivers reporting high levels of acceptance, usability, and 

effectiveness of telehealth services (Gerow et al., 2023; Lindgren et al., 2016). Gerow et al. 

(2023) found that caregivers implement interventions taught via telehealth with high fidelity (i.e., 

95% in their study), while Lindgren et al. (2016) observed that caregivers could learn behavioral 

intervention strategies through telehealth using weekly coaching. Wainer and Ingersoll (2015) 

showed success of a hybrid training model that combined self-developed internet-based training 

31 

 
 
 
modules and telehealth coaching. Broadly, telehealth caregiver training has been found to 

demonstrate advantages in getting caregivers access to intervention (Pacione, 2022) and improve 

outcomes for children with autism (Pickles et al., 2016). Moreover, research indicates that 

telehealth can enhance caregiver fidelity and promote increased interaction during interventions 

(Vismara et al., 2018). 

Limitations in Current Programs 

Several limitations characterize the programs outlined above. One primary limitation is 

the lack of emphasis on caregiver outcomes, as the studies reviewed prioritized child-focused 

outcomes. However, caregivers themselves face significant challenges, including increased 

levels of stress (DesChamps et al., 2020) and risk for psychopathology (Graungaard & Skov, 

2007) during this time. For instance, Kunze et al. (2021) evaluated child RRBIs but did not 

assess caregiver-focused outcomes. Additionally, many reviewed programs targeted specific 

child behaviors with no room for additional behaviors, potentially excluding families whose 

needs do not align with pre-defined targets. This approach may limit accessibility and relevance 

for caregivers seeking support for a broader range of behavioral concerns.  

Two additional limitations are the absence of individualized intervention strategies and 

logistical barriers. Most programs did not incorporate caregiver and child strengths and 

weaknesses into the development of the intervention, and subsequent strategies aligned to those 

strengths and weaknesses, resulting in a lack of tailored support. Logistical barriers also posed 

challenges. For example, Bernie et al. (2021) required some participants to attend in-person 

sessions, which placed a burden on families to travel to access the intervention. 

Furthermore, programs did not provide caregivers with concrete tools or strategies to 

reduce caregiver stress, and many were conducted internationally. Kunze et al. (2021) provided 

32 

 
 
 
 
evidence-based tools for reducing child behavior problems but no strategies for caregivers’ own 

concerns. Moreover, Conolly and Gersch (2013) offered emotional support for caregivers but 

lacked a focus on teaching practical strategies to reduce stress, potentially leaving gaps in 

caregivers’ knowledge, self-efficacy, and stress-reduction techniques. Another limitation is that a 

significant portion of the research in this area has been conducted internationally, such as in 

Ireland and Australia, which may potentially limit the generalizability of findings to the context 

of the United States, including the resources available and the family structures in the United 

States. Lastly, the reviewed studies lack manualization, which could potentially limit their 

replicability and standardized application in diverse settings. 

C-HOPE Addresses Limitations in Current Programs 

The Collaborative Model for Promoting Competence and Success for Hope (C-HOPE) 

holds promise in addressing the limitations of the other types of programs available to families 

on the autism waitlist. C-HOPE places a central focus on caregiver outcomes, aimed to reduce 

caregiver stress and enhance self-efficacy and knowledge about behavior principles and behavior 

management. Unlike many interventions that prioritize child outcomes, C-HOPE recognizes the 

role that caregiver well-being places in supporting their child with suspected autism. In contrast 

to programs that focus solely on emotional support (e.g., Conolly & Gersch, 2013), C-HOPE 

provides caregivers with concrete, evidence-based strategies for managing child behavior and 

coping with their own stress.  

C-HOPE also allows caregiver to select behavioral targets that are relevant to their 

unique needs rather than limiting them to a predetermined set of behaviors that the intervention 

targets. This allows caregivers to work on goals that are relevant to them and their child and 

accommodates a range of presenting concerns.  

33 

 
 
 
C-HOPE further distinguishes itself through its individualized and strengths-based 

approach. The intervention incorporates both caregiver and child strengths and weaknesses into 

the development of tailored behavior interventions plans. Additionally, by offering multi-modal 

delivery, C-HOPE reduces logistical barriers such as travel requirements, which have been cited 

as limitations in past research (e.g., Bernie et al., 2021). Lastly, C-HOPE is a manualized 

program, which enhances its potential for replication, fidelity, and scalability across clinical and 

community settings. 

Collaborative Model for Competence and Success for Hope (C-HOPE)  

The Collaborative Model for Promoting Competence and Success (COMPASS; Ruble et 

al., 2012b) is an ASD-specific evidence-based school consultation intervention designed to 

provide indirect intervention to support children with autism in developing critical social, 

communication, and independent learning skills. The COMPASS model involves developing an 

evidence-based intervention plan, built upon a child’s personal and environmental challenges and 

supports, and guided by high-quality goals across domains most often in need of supports for 

children with this disorder (i.e., social, communication, behavioral, learning and work skills). 

COMPASS is collaborative and includes a consultant, a teacher, a caregiver, and a child to share 

decision making for goal selection and intervention planning. Teachers receive coaching 

throughout the school year to guide their implementation of strategies contained in the plan. The 

efficacy of COMPASS has been demonstrated through three randomized controlled trials (Ruble 

et al., 2010; Ruble et al., 2013, Ruble et al., 2018), highlighting its potential to enhance outcomes 

for students with autism. 

Building on the success of COMPASS, Dr. Ruble and her team developed COMPASS 

for Hope (C-HOPE; Kuravackel et al., 2017), an adaptation of the COMPASS framework aimed 

34 

 
 
 
at improving outcomes in three key areas: decreasing challenging child behavior, reducing 

parenting stress, and increasing parenting sense of competency. C-HOPE utilizes the COMPASS 

framework to identify and address individual child profiles of protective factors and risk factors, 

balancing supports and challenges to promote optimal outcomes.  

C-HOPE is an 8-week parent-mediated intervention that contains both individual (4 

sessions) and group (4 sessions) sessions. Group sessions last approximately 2 hours, while 

individual sessions are about 1 hour long. The group sessions aim to provide foundational 

information on ASD, helping caregivers grasp specific learning differences associated with ASD 

and how they influence their child's behavior, socialization, and communication. Additionally, 

group sessions address parental stress and coping mechanisms. Various coping strategies for 

managing parental stress are introduced, with parents encouraged to identify which ones they 

find effective and consider adopting in the future. These strategies encompass general stress 

reduction techniques, mindfulness-based interventions, and relaxation techniques known to have 

lasting positive effects on stress levels and psychological well-being in parents of children with 

ASD. Individual sessions primarily revolve around formulating, implementing, and refining a 

tailored behavior plan, targeting identified problematic behaviors, and introducing alternative 

skills for each child. 

Moreover, C-HOPE employs a coaching model where trained interventionists collaborate 

with parents to teach them evidence-based strategies and techniques for interacting with their 

child. Through this coaching model, parents become active partners in their child's intervention 

and are empowered to promote their child's behavioral skills in everyday settings.  

Three studies of C-HOPE show evidence of positive effects in both parent and child 

outcomes. In the first study, Kuravackel et al. (2017) investigated the effectiveness of the C-

35 

 
 
 
HOPE intervention. Parents or caregivers (N = 33) were randomly assigned to three different 

groups: receiving the C-HOPE intervention via telehealth, receiving it face-to-face, or being 

placed in a waitlist control group. Parents who received both the face-to-face and telehealth C-

HOPE interventions reported a reduction in parenting stress and an increase in competence. 

Results indicated that all three treatment conditions led to significantly lower adjusted pre-to-

post intervention scores, including child problem behavior posttest scores on the Eyberg Child 

Behavior Inventory (ECBI), though with a small effect (p < .001; d = 0.18). Additionally, there 

was a small effect of C-HOPE on parenting competence as measured by the Being a Parent Scale 

(Johnston & Mash, 1989; p = .02; d = 0.12) and parenting stress as measured by the Parent Stress 

Index (Abidin, 1995; p < .001; d = 0.13).  

In the second study, Dahiya et al. (2021) conducted a secondary analysis of C-HOPE 

(Kurvackel et al., 2017) in rural versus urban settings with a focus on parent competency, 

knowledge, and activation (i.e., knowledge of parent training and supportive strategies) and 

confidence in taking action, as well as child problem behaviors. They used the same manualized 

8-session C-HOPE intervention in a telehealth format. No significant differences between 

caregiver groups were found for the parent measures of competence (p = 0.326; d = .66 [Urban 

group], d = .44 [Rural group]), parent activation (p = 0.453; d = 2.12 [Urban group], d = .91 

[Rural group]), parent knowledge (p = 0.385; d = 1.03 [Urban group], d = 1.31 [Rural group]), or 

child behaviors (p = .566; d = .01 [Urban group], d = .36 [Rural group]). Although the results did 

not reach statistical significance, all caregivers (N = 20) across both rural and urban groups 

reported improvements in competence, parent activation, parent knowledge, and child behaviors 

pre- to post-intervention. Additionally, the effect sizes for parent competence, activation, and 

36 

 
 
 
child behaviors were greater than what Cohen (1988) considers a small effect (d = .20). The 

effect size for parent knowledge surpassed the threshold for a large effect (d = .80).  

In the third study, Rodgers (2018) examined C-HOPE using an adapted asynchronous 

group discussion board, which was developed to support underserved communities. Rodgers 

used the same manualized 8-session C-HOPE intervention. Caregivers (N = 15) had access to the 

materials, watched modules on their own time, and then interacted with other caregivers on the 

discussion boards. The results showed a statistically significant difference in scores for 

challenging child behavior before the intervention (M = 146.40, SD = 35.36) compared to after 

the intervention (M = 123.10, SD = 28.35) and a large effect (d = 0.73). There was also a 

statistically significant difference in scores for parent stress pre- (M = 122.60, SD = 25.73) to 

post-intervention (M = 109.50, SD = 26.47) and a medium effect (d = 0.50). Both effect sizes 

indicated medium to large effects, suggesting a meaningful impact of the intervention. However, 

there was no significant difference in scores for parenting sense of competence before and after 

the intervention. The authors of the study also noted acceptable treatment adherence and social 

validity for the intervention. 

The current research using C-HOPE has demonstrated that training caregivers on 

behavioral foundations, developing an individualized intervention, and coaching them on the 

intervention has reduced caregiver stress, increased caregiver self-efficacy, and reduced child 

behavior challenges. Given the current evidence base for C-HOPE, as well as its use in 

telehealth, with rural families, and through asynchronous modalities, it is possible that it can help 

fill the service gap as an intervention for caregivers on the ASD waiting list.  

37 

 
 
 
 
 
Present Study  

This aims of this are to address a significant gap in the literature by proposing a novel 

approach to bridge services for caregivers of children who are awaiting a diagnosis of ASD using 

the C-HOPE program. This is the first study measuring the effectiveness and acceptability of C-

HOPE, as well as its impact on caregiver stress, self-efficacy, parental knowledge, and child 

behavior problems in sample of caregivers awaiting ASD assessment. 

The unique aspect of this study is that it provides support for caregivers of children who 

are waiting for an evaluation for autism. By identifying and intervening early in the child's 

development, this approach aims to improve outcomes for children with potential ASD by 

providing evidence-based services and supports for their caregivers.  

Low-dose and preemptive interventions, such as C-HOPE, can provide both support and 

positive child outcomes for families (Macduffie et al., 2021). Additionally, a recent meta-

analysis by Hampton and Rodriquez (2021) found that pre-emptive interventions are associated 

with improved parent outcomes, such as the implementation of intervention strategies and 

increased use of behavioral principles. Further, caregivers who participate in parent-mediated 

interventions often demonstrate high fidelity to the intervention at hand (Hampton & Rodriquez, 

2021), which might benefit them down the road for additional interventions that their child may 

participate in in their lifetime. Caregivers are natural change agents in a child’s life, and they will 

be with them for the longest period (Chung & Meadan, 2021). As such, it can be important to 

equip parents with the necessary tools to support their child’s development as they move from an 

evaluation to intervention, and beyond. This study has the goal to improve outcomes for children 

suspected of having ASD and their families by providing early intervention and empowering 

parents to become active participants in their child's school programming and at home. 

38 

 
 
 
  
Emphasis on Caregiver Outcomes 

The current study centers on supporting caregivers of children with suspected autism 

rather than directly targeting child outcomes. As such, the primary focus of this study is on 

targeting caregiver outcomes (e.g., BPS, PSI-4 SF) as opposed to child outcomes (e.g., ECBI). 

This emphasis is due to the relatively brief duration of the intervention, which spans only six 

weeks, potentially limiting its capacity to yield significant behavioral changes in the child. 

Furthermore, both the C-HOPE intervention and the present dissertation are dedicated to 

empowering caregivers of children on the autism evaluation waitlist. This is achieved through an 

emphasis on increasing parental self-efficacy and decreasing stress. 

School Psychology and Practice Model  

School psychologists possess extensive training that enables them to foster 

interdisciplinary collaboration and consultation, recognizing the diverse needs of unique family 

systems and the evidence-based strategies that support them. For example, the National 

Association for School Psychologists (NASP) practice model outlines ten domains of 

professional practice through which school psychologists should be equipped to demonstrate 

knowledge and skills. As demonstrated in the NASP practice model, school psychologists are 

trained and positioned to provide consultation and collaboration with “individuals, families, 

groups, and systems, as well as methods to promote effective implementation of services” (2020; 

Domain 2: Consultation and Collaboration). Expanding on this domain, C-HOPE uses a parent-

training consultation framework, aligning nicely with this area of expertise. Second, the NASP 

practice model also highlights that school psychologists “understand principles and research 

related to family systems, strengths, needs, and cultures; evidence-based strategies to support 

positive family influences on children’s learning and mental health” (2020; Domain 7: Family, 

39 

 
 
 
School, and Community Collaboration). C-HOPE uses the COMPASS profile to identify specific 

strengths and challenges within the family system, thereby fortifying the implementation of C-

HOPE and the intervention plan. 

Expertise in both domains allows school psychologists to bridge the gap between school 

and clinical settings, where evidence-based practices are commonly taught, and the homes of 

families in need of support. Additionally, the C-HOPE intervention reflects these competencies 

through consultation using a family-systems lens. By utilizing consultation effectively, school 

psychologists can translate these evidence-based practices into actionable strategies that can be 

implemented within the family's own environment. 

By providing families with an earlier understanding of basic behavioral principles and 

equipping them with knowledge on how to support their child's development, school 

psychologists can empower caregivers to play a proactive role in their child's behavioral well-

being and development (Hieneman & Fefer, 2017). An early intervention approach may enhance 

the likelihood of a positive response to evidence-based interventions in the future, including 

those that the child may receive during their school-age years. Additionally, parent training 

programs, such as those that use positive behavior supports, can reduce the stress of caregivers 

(Singh et al., 2020), which will hopefully aid them in supporting their child for years to come. 

Through interdisciplinary collaboration, school psychologists can work alongside other 

professionals such as educators, therapists, and early interventionists, ensuring a comprehensive 

approach to supporting children's behavioral and developmental needs. This collaboration allows 

for the integration of evidence-based interventions across different settings, maximizing the 

potential for positive outcomes for the child. Moreover, school psychologists can tailor their 

consultation services to meet the individual needs and cultural backgrounds of families. They 

40 

 
 
 
recognize that each family system is unique and requires individualized support. By considering 

the diverse cultural perspectives and strengths of families, school psychologists can develop 

strategies that are not only evidence-based but also culturally sensitive and appropriate. This 

approach fosters a collaborative and inclusive environment that promotes the well-being and 

success of all children. 

Research Aims and Hypotheses 

The study sought to answer the following research questions.  

Research Question 1   

Do caregivers, who are waiting for an autism diagnostic evaluation for their child and 

participate in the C-HOPE intervention, show a pre-post difference in caregiver stress 

immediately after participating in the C-HOPE intervention, as measured by the Parental Stress 

Index—Fourth Edition Short Form (PSI 4 SF; Abidin 2012)?  

Hypothesis. It was hypothesized that caregivers will show significantly decreased 

overall/total stress following the C-HOPE intervention, as measured by the PSI-4 SF. This 

hypothesis was based on previous research that has found medium effect sizes (Kurvackel et al., 

2017, d = .56; Rodgers, 2018, d = .50) of C-HOPE on caregiving stress measured by the PSI-4 

SF.   

Research Question 2  

Do caregivers, who are in the process of obtaining an autism diagnosis for their child and 

participate in the C-HOPE intervention, show a pre-post difference in caregiver self-efficacy and 

satisfaction immediately after undergoing the C-HOPE intervention, as measured by the Being 

a Parent Scale (BPS; Johnston and Mash 1989)?   

41 

 
 
 
 
Hypothesis 2A. It was hypothesized that caregivers will show significantly increased 

self-efficacy following the C-HOPE intervention, as measured by the BPS. This hypothesis was 

based on previous research that has found a small, but substantive, effect size (Kurvackel et al., 

2017, d = .32) of C-HOPE when examining caregiving self-efficacy measured by the BPS. 

Additionally, prior research indicated that parent training interventions can increase caregiver 

sense of competence (Deb et al., 2020).   

Hypothesis 2B. It was hypothesized that caregivers will show significantly increased 

satisfaction following the C-HOPE intervention, as measured by the BPS. This hypothesis was 

based on previous research that has found a small, but substantive, effect size (Kurvackel et al., 

2017, d = .32) of C-HOPE when examining caregiving self-efficacy measured by the BPS.  

Research Question 3 

Do caregivers, who are in the process of obtaining an autism diagnosis for their child and 

participate in the C-HOPE intervention, show a pre-post difference in parent knowledge about 

parent training and supportive strategies immediately after undergoing the C-HOPE intervention, 

as measured by the Parent Knowledge Questionnaire (PKQ; Dahiya et al., 2021)?   

Hypothesis 3. It was hypothesized that caregivers will show significantly increased 

parent knowledge about parent training and supportive strategies following the C-HOPE 

intervention, as measured by the PKQ. This hypothesis was based on previous research that has 

found a unsignificant findings but with large effect sizes (Dahiya et al., 2021, d = 1.03 [Urban 

group], d = 1.31 [Rural group) of C-HOPE when examining parent knowledge measured by the 

PKQ.  

Research Question 4    

Do children of caregivers, who are in the process of obtaining an autism diagnosis for 

their child and participate in the C-HOPE intervention, show a pre-post difference in child 

42 

 
 
 
behavior intensity immediately after their caregivers participate in the C-HOPE intervention, as 

measured by the Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 1999)?  

Hypothesis 4 Research question 4 was exploratory, as children will receive behavioral 

support from their caregiver for only three weeks and data will only be tracked four times. It was 

hypothesized that there would be a downward trend in intensity scores, indicating a decrease in 

behavioral challenges from pre- to post-intervention. Previous studies have indicated that 

children whose caregivers participated in C-HOPE exhibited a decrease in behavior intensity 

scores from pretest to posttest (e.g., d = .18 (Kurvackel et al., 2017). 

Research Question 5 

How do families perceive the acceptability of the intervention, intervention 

appropriateness, and feasibility of the intervention, as measured by a post-intervention rating 

scale and focus group?  

Quantitative and qualitative data was used to examine research question 5. The AIM, 

IAM, and FIM measure provided quantitative data, while the focus group provided valuable 

supplementary context to the quantitative findings to better understand how to support future 

implementation. Specifically, it was hypothesized that caregivers would find the C-HOPE 

intervention to be useful in terms of its content, usability, and accessibility, and caregivers will 

report that the C-HOPE intervention was advantageous in reducing their caregiving stress and 

increasing their self-efficacy around parenting. Prior research has found that parent training 

interventions for toddlers were acceptable and applicable to the lives of caregivers of children 

with ASD (Beaudoin et al., 2014). Parent training interventions can also increase autism-specific 

parenting skills (Ho & Lin, 2020). As such, it was hypothesized that these interventions can, too, 

support caregivers who have a child who is likely to have an ASD but is not diagnosed. Prior 

43 

 
 
 
studies using C-HOPE have found high satisfaction with the intervention. For example, 

Kurvackel et al. (2017) found that participants generally rated that they were ‘very satisfied’ on a 

4-point Likert-type scale (M = 3.7). Additionally, prior studies have found the C-HOPE 

intervention to reduce caregiver stress and increase caregiver self-efficacy (Dahiya et al., 2022; 

Kurvackel et al., 2017).  

Hypothesis 5. It was anticipated that the focus group would uncover nuanced aspects of 

caregivers' experiences and perceptions that may not be fully captured through quantitative 

measures alone. The mixed methods approach reflects a growing recognition in the field of the 

importance of contextual factors in shaping treatment response and intervention uptake. Through 

qualitative exploration, I aimed to dive deeper into the underlying reasons behind caregivers' 

ratings and responses, identifying the specific components of the intervention that resonated 

most strongly with them as well as those that did not. Furthermore, focus groups can provide an 

opportunity to explore caregivers' perceptions of the intervention's impact on reducing caregiving 

stress and increasing self-efficacy in parenting, including if the strategies taught were helpful or 

not. I anticipated that they would find them helpful. Beyond quantifying the AIM/IAM/FIM, I 

anticipated that the qualitative data would elucidate the mechanisms through which the 

intervention facilitated changes in caregiving stress and self-efficacy, which can provide valuable 

information for refining future iterations of the intervention. Additionally, by engaging in a focus 

group with caregivers, I anticipated that I would find areas for improvement that may not have 

been evident from the quantitative measures. For example, I might learn about the challenges or 

barriers they encountered in implementing it within their daily lives. By understanding these 

contextual nuances, I hoped to identify ways to enhance the intervention's scalability and 

effectiveness for caregivers. 

44 

 
 
 
Participants  

METHOD 

A total of seven caregiver participants were recruited for the study. Demographic data 

were collected from both caregivers and their children to provide a profile of the participants 

(See Table 1). Caregiver gender was collected, with two participants identifying as male and five 

identifying as female. Caregivers ages spanned from 37 to 43 years (M = 39; SD = 2.37). 

Regarding caregiver ethnicity, most caregiver participants (5; 71%) were White. Caregivers were 

asked about their own medical and psychological history, with one (14%) caregiver reporting a 

diagnosis of ADHD. In terms of education level, most caregiver participants (5; 71%) had 

completed some graduate school or earned a graduate degree. Caregiver marital status was also 

collected. Seven (100%) of the caregivers were married. In terms of income, families reported 

their total gross household income from the previous year. Most caregivers four (57%) earned 

between $100,001 to $200,000.  

Child Demographics  

Demographic data were collected for the child who was on the evaluation waiting list for 

autism concerns (see Table 1). Child gender was recorded, with caregivers reporting that four 

(57%) children identified as male and three (43%) identified as female. The children's birthdates 

were also collected, with caregivers reporting age ranges spanning from 5 to 12 years (M = 8.30; 

SD = 2.93). Regarding ethnicity, most caregivers reported that children (4; 57%) identified as 

White. Most children were in elementary school (5; 71%) while the other two children (29%) 

were in middle school. Participants were also asked whether a doctor, nurse, psychologist, or 

other medical/school professional had provided their child with any other medical diagnosis. 

Caregivers reported that five (71%) of the children were diagnosed with an anxiety disorder. 

45 

 
 
 
 
Participants were asked whether the child currently received services. Caregivers reported that 

three (43%) of the children were reported to be receiving services, including therapy and 

occupational therapy. Refer to Table 1 for additional details about caregiver and child 

background information.  

Social Communication 

Caregiver reported SCQ scores (N = 7) ranged from 21 to 28 (M = 24.14; SD = 2.91).  

Services Information 

Caregivers were asked to provide information about the evaluation request for their child. 

Caregivers were asked whether this evaluation was an initial evaluation. Two (29%) caregivers 

indicated that the evaluation was solely for autism spectrum disorder (ASD). The individuals 

who requested the evaluation were also recorded. Five (71%) of caregivers indicated that they 

requested the evaluation through a psychologist. Caregivers were asked how long they had been 

waiting for an evaluation. The waiting time distribution varied with most caregivers (3; 43%) 

indicating that the clinic estimated waiting for approximately reporting 11 to 12 months. Finally, 

the current waiting time varied with most caregivers (3; 43%) reporting five to six months since 

they were added to a waiting list. 

C-HOPE Groups 

The principal investigator planned for each group to comprise approximately eight to ten 

participants for a total of three to four groups. Given reasons such as attrition and difficulty 

recruiting parents to the study, the intervention was implemented with seven caregivers across 

three groups (group 1: 3 participants, group 2: 2 participants, and group 3: 2 participants). 

Participants were not matched based on demographic or baseline variables; instead, group 

46 

 
 
 
 
 
assignment was based on the order and timing in which caregivers enrolled in the intervention 

study.  

Table 1 

Caregiver and Child Demographics  

Characteristic 

Gender  

Male 
Female 

Age (years) 

Mean (SD) 
Min-Max 

Race/Ethnicity 
White 
Black/African American 
Two or More Races 
Medical or Mental Health History 

ADHD 
Anxiety  

Additional Services Received 
Mental Health Therapy 
Occupational Therapy 

Highest Level of Education 

Some elementary school 
Some middle school 
Some high school 
High school diploma 
College/University degree 
Some graduate school 
Graduate degree (master’s 
degree or higher) 

Marital Status 

Married 

Gross Income 

$50,001 to $75,000 
$75,000 to $1000 
$100,01 to $200,000 
$200,00 or more 

Caregiver 
n (Percentage) 

Child 
n (Percentage) 

2 (29%) 
7 (71%) 

39 (2.37) 
37 - 43 

5 (71%) 
2 (29%) 
0 (0%) 

1 (14%) 
0 (0%) 

- 
- 

0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
2 (29%) 
2 (29%) 
3 (43%) 

7 (100%) 

0 (0%) 
1 (14%) 
4 (57%) 
2 (29%) 

4 (57%) 
3 (43%) 

8.30 (2.93) 
5 - 12 

4 (57%) 
2 (29%) 
1 (14%) 

0 (0%) 
5 (71%) 

1 (14%) 
2 (29%) 

- 
- 
- 
- 
- 
- 
- 

- 

- 
- 
- 
- 

Note: “- “indicates that the question was not applicable  

47 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility Criteria 

To be eligible for the study, caregivers lived in Maryland or Michigan and had a child 

between the ages of three and 13 years who was on an evaluation waitlist for autism concerns 

and displayed behavioral concerns. Children scored 15 or higher on the Social Communication 

Questionnaire (SCQ; Rutter et al., 2003) or three or higher on the Modified Checklist for Autism 

in Toddlers (M-CHAT; Robins et al., 2009) to be eligible (measures are described below). These 

cutoff scores on each measure suggest that the individual was likely to be on the autism 

spectrum. Finally, to establish whether children exhibited clinically significant behavioral 

difficulties, parents completed the ECBI assessment upon intake. Children with a T-Score of 60 

or higher were eligible. This criterion was needed, as one objective of this dissertation is to 

address and mitigate problematic behavior in children. Therefore, children with elevated 

behavioral concerns and their caregivers were sought as they were deemed most likely to benefit 

from the intervention. 

Measures  

Demographic Form  

A demographic form was administered to collect information about the caregiver 

participants and their child (see Appendix A).  

Autism Screener 

Two screeners were used during the recruitment process to screen the child for autism 

symptoms. Two screeners were chosen depending on the age of the child.  

Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F; 

Robins et al., 2009). If the caregiver had a child below the age of four years, the Modified 

Checklist for Autism in Toddlers (M-CHAT; Robins et al., 2009) was used. It is a 20-item 

48 

 
 
 
 
 
 
screening tool for autism in toddlers between 16 and 30 months of age regarding typical and 

atypical development behaviors commonly observed in autism. It is free for clinical, research, 

and educational use and requires little to no training to administer. The M-CHAT-R/F was 

developed to improve the utility of the M-CHAT (Robins et al., 2009). Sample questions are 

“Does your child play pretend or make-believe?” and “If something new happens, does your 

child look at your face to see how you feel about it?” Responses are based on “yes” or “no,” and 

are summed to get a total score. A threshold of raw score = three was used in the current study to 

determine moderate risk for ASD. The cut-off served to aid in characterizing the sample and 

assisting in the determination of whether the child is at risk for an ASD.  

The M-CHAT-R/F has demonstrated the ability to detect ASD in toddlers (Robins et al., 

2014). In the Robins et al. (2014) study, the M-CHAT-R/F was able to identify ASD in 105 of 

123 toddlers with ASD, indicating a sensitivity of 0.85 and specificity of 0.99. Research studies 

have indicated that the M-CHAT has a sensitivity as high as 0.92 and a specificity as high as 

0.93 when supplemented with a telephone follow-up (Dumont-Mathieu and Fein, 2005; Snow & 

Lecavalier, 2008). Robins and colleagues (2014) found that the M-CHAT has a below-adequate 

(α = 0.63) to adequate internal consistencies (α = 0.79). The authors note that this is not 

surprising as the M-CHAT-R does not assess a unitary dimension. In the original validation 

study (Robins et al., 2014), the two-stage screening was used, and internal consistencies were 

adequate (α = 0.79). Further in a recent meta-analysis, Aishworiya et al. (2023) found that the M-

CHAT-R/F has a moderate pooled positive predictive value for Autism (57.7%; 95% CI 48.6 – 

66.8) and 89% PPV for any developmental disorder (95% CI 82.9–94.6), such as a global 

developmental delay.  

49 

 
 
 
 
Social Communication Questionnaire (SCQ; Rutter et al., 2003). If the caregiver had 

a child above the age of four years, the Social Communication Questionnaire (SCQ; Rutter et al., 

2003) was provided. The SCQ is used to identify symptoms associated with autism spectrum 

disorder (ASD) in children aged 4 and older. The SCQ consists of 40 yes/no questions that assess 

communication skills and social functioning in children with a potential ASD diagnosis. The 

items on the SCQ are aligned with the Autism Diagnostic Interview-Revised (ADI-R; Corsello et 

al., 2007; Bölte et al., 2008), which is one gold-standard measure for diagnosing autism. 

The SCQ is a parent-report screening measure. There are two forms of the SCQ. The 

SCQ Current form asks caregivers to respond about their child’s behavior during the last three 

months. The SCQ Lifetime asks caregivers to respond to whether behaviors have ever been 

present and if they have been present in the last 12 months. The SCQ Lifetime form was used in 

the current study. Sample questions on the SCQ are “Is she/he now able to talk using short 

phrases or sentences” and “Has her/his facial expression usually seemed appropriate to the 

particular situation, as far as you can tell?” Responses are based on “yes” or “no”, with responses 

receiving a value of 1 point for abnormal behavior (i.e., “yes”) and 0 points for the absence of 

abnormal behavior/normal behavior (i.e., “no”). The recommended cutoff score indicative of the 

likelihood of ASD is 15, prompting the need for further comprehensive evaluations, but some 

research has found that a lower cutoff score may be used. However, some research has suggested 

a cut-off score of 11 (Rosenberg et al., 2018). Research suggests that a cutoff score of 11 has a 

sensitivity of 0.88 and a specificity of 0.83 to 0.95 (Rosenberg et al., 2018). A cut-off score of 11 

was used for the current study. Research indicates there is high convergent validity between the 

SCQ and the ADI-R (Rutter et al., 2013). The SCQ also demonstrated good internal consistency 

50 

 
 
 
 
reliability with a coefficient alpha of 0.94 for verbal children and 0.89 for nonverbal children 

(Marvin et al., 2017).  

Caregiver Stress 

Parental Stress Index—Fourth Edition Short Form (PSI4SF; Abidin, 2012). 

Caregiver stress was measured using the Parenting Stress Index – Fourth Edition (PSI-4 SF; 

Abidin, 2012). The PSI-4 is a 120-item parent-report measure of caregiver stress. It is intended 

for caregivers of children up until the age of 12 years. The PSI-4 SF can be administered 

individually or in group settings.  

The PSI-4 SF has three scales, including a child domain, parent domain, and life stress 

domain, where the child and parent domain combine to form the total stress scale. For the current 

study, the total stress scale was used. The parent subscale includes seven subscales: competence, 

isolation, attachment, health, role restriction, depression, and spouse/parenting partner 

relationship. The child subscale includes six subscales: distractibility/hyperactivity, adaptability, 

reinforces parent, demandingness, mood, and acceptability. The life stress scale includes 19 

dichotomous items that ask caregivers if they have experienced any of the events listed in the 

items within the past 12 months. Responses in the parent and child domains are rated on a Likert-

type scale (i.e., 5 - strongly agree to 1 - strongly disagree). Responses in the life stress domain 

are reported as “yes” or “no” (i.e., 1 or 0). Sample questions include, “Since having this child, I 

have been unable to do new and different things” and “I feel alone and without friends.” T-scores 

between the 16th to 84th percentile are considered normal, 85th and 89th percentiles are interpreted 

as high, while scores in the 90th percentile are interpreted as clinically significant.  

The PSI-4 SF is a well-established, validated measure of caregiver stress. The PSI-4 was 

validated with a diverse sample, including a range of races/ethnicities and educational levels 

51 

 
 
 
 
(Johnson, 2015). It has also been used with caregivers of autistic children. Considering that 

caregivers of children with ASD report higher stress, the PSI-4 SF demonstrated reliable and 

valid data in accurately capturing the stress experienced within this specific population 

(Zaidman, et al., 2010). In the normative sample for the PSI-4, the coefficient alphas (i.e., 

reliability) of child and parent domains were 0.96 and 0.98 for the total stress scale (Abidin, 

2012). Test-retest was measured with a sample of 30 mothers. Correlation coefficients were 0.63 

for the child domain, 0.91 for the parent domain, and 0.96 for the total stress (Abidin, 2012). In 

addition, the PSI-4 SF has strong treatment sensitivity (Holly et al., 2019).  

Caregiver Sense of Competence  

Being a Parent Scale (BPS; Johnston and Mash 1989). Parent-reported sense of 

competence was measured using the Being a Parent Scale (BPS; Johnston & Mash, 1989). The 

BPS is a 16-item questionnaire that parents complete to assess their perception of their parenting 

competence. It covers various aspects such as satisfaction with their parenting role (including 

frustration, anxiety, and motivation) and their confidence as parents (including competence, 

problem-solving abilities, and capability in the parenting role). Sample items include, “Even 

though being a parent could be rewarding, I am frustrated now while my child is at his/her 

present age” and “Being a parent is manageable and any problems are easily solved.”  

Items on the BPS comprise two factors: satisfaction (9-items) and efficacy (7-items). 

These two scales, when combined, form the total score. Items are rated on a six-point Likert 

scale (Strongly agree - 5 to Strongly Disagree - 1), with higher scores indicating a higher 

parenting sense of competence. For the current study, the raw scores were used. 

The internal consistency of the BPS total score in past studies has been 0.82 

(Whittingham et al., 2009). Internal consistency for the total score (α =.79), satisfaction factor (α 

52 

 
 
 
 
=.75), and efficacy factor (α =. 76) have been reported (Johnston & Mash, 1989). The BPS has 

been used in a few studies with samples of caregivers who have autistic children (e.g., Dahiya et 

al., 2022; Kuravackel et al., 2017). The reported total score reliability estimate by Kuravackel et 

al. (2017) was 0.85 to 0.87. No measure of reliability was reported in the Dahiya et al. (2022) 

study.  

Caregiver Knowledge 

Parent Knowledge Questionnaire (PKQ). The Parent Knowledge Questionnaire (PKQ; 

Dahiya et al., 2021) was used to measure parents’ knowledge of parent training and the strategies 

taught in C-HOPE (see Appendix B). The PKQ is an 18-item scale that is scored on a four-point 

Likert scale. Each item asks the caregiver a question about a specific parenting strategy or 

behavioral principle taught during C-HOPE. The PKQ is scored based on how many items that 

caregiver endorsed, suggesting how much the caregivers’ knowledge changed from pre to post 

intervention. The change score was calculated by subtracting the pre-score from the post-score, 

and positive change scores will reveal an increase in parent knowledge. In the current study, the 

18-item PKQ was adapted to a 17-item PKQ as one question was removed (i.e., “my child’s 

characteristics of autism”)  

Child Behavior 

Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 1999). Child behavior 

concerns was measured using the Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 

1999). The ECBI is a parent-report measure consisting of 36-items designed to assess problem 

behavior in children aged 2 to 16 years. The ECBI can be used to serve as a screener for problem 

behavior in children and be used as a tool to monitor a child’s behavior during treatment. It can 

be completed in-person, online, or over the phone.  

53 

 
 
 
 
The measure incorporates two scales: the 'intensity' scale, which evaluates the quantity 

and frequency of challenging behavior problems, and the problem' scale, which reflects the 

parent's level of tolerance towards these behaviors and the distress they cause. Items on the 

problem scale are rated as “yes” or “no” (0 or 1) and items on the intensity scale are rated on a 

seven-point Likert scale (Never – 1 to Always - 7) Sample items include “dawdles in room” and 

“argues with parents about rules.” ECBI Intensity Scale T-scores at or above 60 are considered 

clinically significant. ECBI Problem Scale T-scores at or above 60 are considered clinically 

significant. The ECBI intensity scale was used for this study to capture the frequency occurrence 

for each behavior item.  

Various studies have demonstrated high test-retest reliability (above 0.75) and strong 

internal consistency (alpha) for both scales. For example, Morawska & Sanders (2006) reported 

good internal consistency for the intensity scale (α =. 91) and problem scale (α = 0.87), while 

Colvin et al. (1999) reported good internal consistency for the intensity scale (α =. 95) and 

problem scale (α = 0.93). Evidence for construct validity has also been found (Abrahamse et al., 

2015; Funderburk et al., 2003). Boggs et al. (1990) reported that the ECBI scales were correlated 

with the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), with Pearson 

correlation coefficients ranging from 0.65 to 0.86. There is also evidence to indicate the ECBI 

can detect change and has good sensitivity to change (Hutchings et al., 2011; Sofronoff et al., 

2011; Zubrick et al., 2005).  

Therapist and Client Factors  

Consultant Fidelity Adherence Checklist. A procedural fidelity checklist form was 

used to ensure the interventionists adhered to the C-HOPE manual (Kuravackel et al., 2017). 

This procedural fidelity checklist was written by the developers of C-HOPE (Kuravackel et al., 

54 

 
 
 
 
2017; see Appendix D), and adapted to align with the current study procedure. Sample items on 

this checklist include, “the therapist explained the purpose of the session and an overview of the 

upcoming sessions” and “the therapist helped me identify my child’s personal and environmental 

challenges and strengths.” Items were answered as “yes” or “no” and the scores were summed. 

No psychometric properties are available for this scale. Treatment fidelity from the two studies 

using this tool ranged from 76.2% to 100.0% (M = 94.2, SD – 7.1; Kuravackel et al., 2017; 

Rodgers et al., 2018). 

Post-Session Questionnaire. Caregivers completed a post-session questionnaire after 

each session to assess caregiver comfortability with using strategies taught in C-HOPE and 

feasibility with using strategies taught in C-HOPE. Additionally, this questionnaire asked 

caregivers if they used any other resources during the time of the intervention. If they did, they 

had the opportunity to explain what resources they used. This questionnaire was developed by 

the principal investigator (see Appendix B).   

Acceptability  

Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure 

(IAM), and Feasibility of Intervention Measure (FIM; Weiner et al, 2017). Caregivers 

completed the Acceptability of Intervention Measure (AIM), Intervention Appropriateness 

Measure (IAM), and Feasibility of Intervention Measure (FIM) to measure their perceptions of 

the acceptability, appropriateness, and feasibility of the intervention (see Appendix C). Items are 

rated on a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree). 

Cut-off scores are not yet available; however, higher scores indicate greater acceptability, 

appropriateness, and feasibility. A sample item from the measure is “the intervention meets/met 

my approval” and “the intervention seems/is implementable,” Caregivers completed the AIM, 

55 

 
 
 
 
IAM, and FIM post-intervention. According to Weiner at el. (2017), the measure has strong 

validity and reliability. In their study, Cronbach alphas for the 4-item scales were 0.85 for 

acceptability, 0.91 for appropriateness, and 0.89 for feasibility. Alhejailan (2024) used the AIM, 

IAM, and FIM measure in their study that investigated a parent-mediated intervention for 

toddlers at risk for ASD. They found test-retest reliability coefficients between 0.73 to 0.88. and 

Cronbach α’s were 0.85 to 0.91. Another study investigating the feasibility of an interpersonal 

effectiveness skills parent training program for adolescents with ASD found α = .69 for AIM, α 

= .94 for IAM, and α = .96 for FIM (Easley, 2023).  

Focus Group. Caregivers participated in a one-hour focus group aimed at better 

understanding their qualitative insights about the intervention. Caregivers were asked questions 

developed by the PI such as “what were some strengths to the C-HOPE intervention?” and “Of 

all the things we covered in the C-HOPE intervention, what was most important to you?” See 

Appendix F for a complete list of focus group questions.  

Design 

A single group pre-post design was used to explore the effects of C-HOPE on variables 

of caregiver knowledge about behavioral principles, caregiver self-efficacy, caregiver stress, and 

child problem behavior. The independent variable was the intervention. The primary dependent 

variables were caregiver self-efficacy measured by the BPS, caregiver stress measured by the 

PSI-4 SF, and parent knowledge measured by PKQ. Caregiver satisfaction was measured to 

understand caregiver perceptions about the relevance, usefulness, and usability of the 

intervention and was measured by the AIM/IAM/FIM. The BPS and PSI-4 SF were administered 

at pre-intervention and post-intervention, the PKQ was administered at session 1 and session 6, 

while the AIM/IAM/FIM was administered post-intervention. The secondary dependent variable 

56 

 
 
 
 
 
is child behavior measured by ECBI and is considered exploratory and was administered at pre-

intervention and post-intervention. Table two illustrates the measurement schedule.  

A single group pre-post design was intentionally selected over a randomized controlled 

trial (RCT) for several strategic reasons. First, it was chosen to optimize participant recruitment 

into the treatment group. Second, an RCT typically extends the duration of the study due to the 

necessity of including a control group, such as a waitlist control group. This sequential 

arrangement, with the treatment group preceding the control group, inevitably prolongs the 

timeline of the dissertation study. A single-group pre-post design is particularly useful when it is 

not feasible or ethical to have a control group, or when the main objective is to evaluate changes 

within a specific group rather than comparing different groups. Additionally, it could be 

potentially maleficent not to offer the intervention to all participants.  

Procedure 

All procedures were approved by the Michigan State University Human Subject Research 

Protection Program (HRPP; HRPP/IRB STUDY00010147). 

Recruitment  

Caregivers were recruited through a comprehensive range of channels to ensure a diverse 

and representative participant pool. The recruitment process employed multiple methods, 

including contacting local clinics, using their listservs, using social media platforms (i.e., 

Facebook and Instagram), and through word-of-mouth referrals. Recognizing the pivotal role 

played by local clinics in supporting families on the autism evaluation waitlist, the principal 

investigator established contact with the clinics and collaborated with them. This collaboration 

involved requesting the clinics to share information about the study with the families who are on 

an evaluation waiting list for autism concerns at their clinic. Those who were interested were 

57 

 
 
 
 
 
 
provided a flyer that has a quick response (QR) code on it, which directed them to an interest 

form. They then filled out the form indicating their interest and then the principal investigator 

shared with them a recruitment email containing information about the study and directed them 

to a link to fill out a screening survey. Figure 3 provides a breakdown of the families who 

expressed interest and those who completed a screening survey.  

Locating families who are waiting for an autism evaluation for their child proved to be 

particularly challenging. Forty clinics and doctor offices (e.g., pediatricians), four hospital 

systems, 11 pre-schools, and five special education departments were contacted. Of the 60 sites 

contacted, 27 (45%) agreed to share the study materials with their patients. Of the 27 sites, the PI 

personally presented the project virtually at 6 (22%) of them.  

This group represents a niche population that is often under significant stress and may not 

be actively seeking out additional commitments. The difficulty in identifying and engaging these 

families can be attributed to several factors. First, families in this situation are often navigating a 

complex and overwhelming healthcare system. The wait for an autism evaluation can be lengthy, 

and during this time, families may be focused on managing their child's immediate needs rather 

than participating in research studies. This was expressed by some families who explained that 

the timing was not right for them or that they were not able to commit to the participation 

timeline. Second, I had difficulty identifying clinics and programs that would allow me to recruit 

through their listservs. 

Another recruitment issue was losing contact. For example, some families expressed 

interest but subsequently lost communication. This loss of contact could be due to changes in 

busy family schedules or a shift in priorities. The PI attempted to re-initiate communication two 

times for each participant who he lost contact with.

58 

 
 
 
 
Attrition. Attrition occurred in several ways. First, several families expressed initial 

interest in participating but did not complete the screening measures. This could be attributed to 

various factors such as the complexity of the screening process, time constraints, or a lack of 

immediate perceived benefit from participation. Secondly, there were families who enrolled in 

the study but later dropped out due to personal reasons. These reasons ranged from personal 

emergencies to changes in family dynamics that made participation untenable.  

59 

 
 
 
 
 
Figure 3 

Recruitment and Retention of Study Participants  

Expressed Interest in 
Program 
(n = 54)

Filled Out Eligibility 
Screening Form 
(n = 22)

Enrolled in Program 
(n = 10) 

Completed Program
(n = 7)

Recruited through:
Clinic (n = 17) 
Flyer (n = 21)
Did not report (n = 16)

Of the 54 interested participants, 
32 participants did not fill out a 
screening form due to loss of 
contact or no longer interested  

Of the 22 participants who filled 
out an eligibility screening form, 
12 participants partially filled out 
the screening form and 10 
participants filled out the full 
screening form.

Recruited through: 
Clinic (n = 5)
Flyer (n = 3)
Did not report (n = 2)

Recruited through:
Clinic (n = 3)
Flyer (n = 4)

Note: three caregivers enrolled in the program but dropped out. Two caregivers dropped out due to scheduling conflicts with their day-

to-day responsibilities, while the reasons the other caregiver discontinued is unknown to the PI.  

60 

 
 
 
 
 
Data Collection Procedures 

Table 2 summarizes at what time point each measure was administered and the mode of 

administration. Data collected from each instrument was exported from PAR iConnect and 

Qualtrics and imported into Excel using an item-level data download to ensure accuracy and 

consistency in scoring. Finally, all the data was uploaded from Excel into Statistical Software for 

the Social Science Version 27 (SPSS Version 27) for analysis. 

Screening Process. The screening process assessed if the family had a child between the 

ages of 3 and 12 years old on an evaluation wait list for autism concerns, displayed behavioral 

concerns per the ECBI measure, and met the cutoff scores on the M-CHAT or SCQ. Specifically, 

a cut-off score of 3 on the M-CHAT or a cut-off score of 15 on the SCQ, and a cut-off score of 

60 on the ECBI was used as the criteria for eligibility. Additionally, at least one caregiver 

participated. Families who met all of these criteria were considered eligible to participate in the 

study.  

Those who did not meet the screening criteria and were deemed ineligible were thanked 

for their time and redirected to conclude the survey, acknowledging their effort in the screening 

process. On the other hand, participants who met the screening criteria, proceed to the next step. 

They were provided with an electronic consent form designed to offer a comprehensive 

understanding of the study’s purpose, procedures, and the format in which the research was 

conducted. After reviewing the consent form, participants who remained interested in 

participating were requested to complete the form, thereby formally expressing their informed 

consent to join the study. This process ensured that eligible participants were fully informed 

about the study and voluntarily choose to participate, fostering a transparent and ethical approach 

to research participation. See Figure 3.  

61 

 
 
 
 
Pre-Treatment. Caregivers who qualified for the study completed baseline data 

collection measures, including the BPS, PSI-4 SF, PKQ, and ECBI. All measures were 

completed online through Qualtrics or PAR iConnect.  

Post-Treatment. After the C-HOPE intervention, caregivers completed post-treatment 

data collection measures, including the BPS, PSI-4 SF, PKQ, ECBI, and AIM/IAM/FIM. All 

measures were completed online through Qualtrics or PAR iConnect. In addition, caregivers 

participated in a single-session focus group.  

Missing Data. To ensure robust data collection using a small sample size, a strict 

approach was planned to address missing data. Following each session, all measures were 

thoroughly reviewed. I examined the collected measures. In cases where caregivers accidentally 

missed a question on any of the measures, I planned to reach out to the families by phone to 

obtain answers to the missed questions. This personalized approach planned to address any 

inadvertent omissions and ensure comprehensive data collection. However, any measures 

remaining incomplete, despite my efforts to obtain the missing information, would be considered 

incomplete and excluded from the subsequent analyses. This rigorous approach safeguarded the 

integrity of the data set, allowing only fully completed measures to be included in the final 

analysis. Incomplete data from the screening form and data from the participants who dropped 

out of the study (n = 3) were excluded in the dissertation and subsequent analysis.  

62 

 
 
 
 
 
 
 
 
 
Table 2 

Data Collection Procedures 

Timepoint 

Measures Administered  Mode of Administration 

Pre-Intervention/ 
Screening 

Session 1 
Self-Directed 

Session 2 
Self-Directed 

Session 3 
Group 

Session 4 
Individual 

Session 5 
Group 

Session 6 
Individual 

Post-Intervention 

Screening Survey 
M-CHAT or SCQ 
BPS 
PSI-4 SF 
ECBI 

Demographic Form 
Post-Session Survey 
PKQ 
COMPASS Profile 

Qualtrics 

PAR iConnect 

Qualtrics 

COMPASS website 

Post-Session Survey 

Qualtrics 

Post-Session Survey 

Qualtrics 

Post-Session Survey 

Qualtrics 

Post-Session Survey 

Qualtrics 

AIM/IAM/FIM 
PKQ 
Post-Session Survey 

PSI-4 SF 
ECBI  
BPS 

Qualtrics 

PAR iConnect 
Qualtrics 

Focus Group 

Focus Group Questions 

Administered on Zoom by 
interventionist 

Intervention Procedure 

Adapted C-HOPE 

I adapted the program based on the original pilot study conducted by Kuravackel et al. 

(2017), hereby called “original C-HOPE” for the manualized program developed by Kuravackel 

63 

 
 
 
 
 
 
  
 
 
  
  
  
  
 
 
 
 
 
 
et al. (2017) and “adapted C-HOPE” for the current dissertation study. The manualized, original 

C-HOPE intervention consisted of eight sessions, including four individual sessions and four 

group sessions. The adapted C-HOPE consisted of six sessions (see Table 4 for a comparison of 

the original versus adapted C-HOPE). In the adapted C-HOPE, groups one and two consisted of 

six sessions, including a mix of self-directed and synchronous meetings led by the 

interventionists. Group three consists of the same six sessions but were delivered virtually. The 

shift to the fully virtual format was due to families expressing that they could not come to in-

person sessions. To meet recruitment goals, I made the decision to provide C-HOPE virtually. 

The overall structure, material covered, and number of the sessions did not differ. See Table 5 

for an outline of each. 

The original C-HOPE intervention was designed for caregivers of children who have an 

autism diagnosis. The rationale behind adapting the eight-session original C-HOPE intervention 

to six-sessions adapted C-HOPE intervention was to better cater to caregivers of children who 

have not yet received an official autism diagnosis. The didactic training portions of the six-

session intervention was adapted to focus more on teaching behavioral principles and promoting 

positive parenting practices. As a result, it did not include the usual session covering topics such 

as cognitive theories of autism, autism education, and local resources on autism. In addition, 

session seven and eight were condensed into one session due to having an additional problem-

solving and reflection component in session five. The content targeting caregiver stress and child 

behavior remained the same such that different outcomes would not be expected. For a detailed 

comparison of the modifications made from the original manualized C-HOPE intervention to its 

current adaptation, please refer to Table 4. 

64 

 
 
 
 
 
In the first session, participants engaged in a pre-recorded online module that lasted for 

approximately 30 minutes. This module provided an overview of C-HOPE's goals, introduced 

the assessment process, and helped caregivers identify initial goals using the COMPASS profile 

(see Appendix G). This profile emphasizes clinical decision-making based on the three elements: 

child strengths, parent and family resources, and evidence-based practices. The profile results in 

a personalized plan that considers the interaction between the child’s personal and environmental 

challenges and supports. Caregivers received instruction on how to fill out the COMPASS 

profile in session one and then asked to fill out a draft of the COMPASS profile as homework 

after session three. The interventionist collaboratively worked with the caregiver to review the 

draft, make sure it was filled out correctly, identified goals, and developed a plan in session four.  

In the second session, also a pre-recorded online module, caregivers were introduced to 

the antecedent-behavior-consequences (ABCs) of behavior, as well as proactive, reactive, and 

teaching strategies. The session also delved into a discussion on caregiver stress and common 

strategies for reducing caregiving stress. Furthermore, a "wellness" package was reviewed, 

consisting of activities designed to identify strategies for self-care and relaxation. The module 

concluded by introducing a relaxation strategy.  

Session three took the form of a two-hour group meeting lasting approximately – 

conducted in-person for groups two and three and virtual for group three. Participants engaged in 

discussions about teaching strategies and positive behavior approaches to prevent disruptive 

behaviors while teaching new skills. For example, participants were taught how to provide 

effective commands and use visual supports to support understanding of the commands. 

Additionally, the session addressed the crucial role of parents and caregivers as essential 

65 

 
 
 
 
 
"environmental supports" for the child. At the end of the session, participants provided feedback 

about how feasible it was to use these strategies through an end-of-session survey. 

Session four involved a one-hour individual meeting between the caregiver and 

interventionist – conducted in-person for groups two and three and virtual for group three. 

Together, the caregiver and interventionist identified one target behavior (i.e., behavior they 

want to focus on in the intervention) to decrease and generate replacement skills to increase. 

During this session, the focus was on identifying the specific behavior they wanted to work on 

and the development of the child's personalized behavior plan. Guidance on how to implement 

the strategies to target the behavior occurred during this session. See Table 3 for behaviors 

targeted and strategies taught and Appendix J for a full case example. 

The fifth session was another group meeting lasting approximately one hour, conducted 

virtual for all three groups. The focus of this session centered on problem-solving and reflection, 

allowing for peer-to-peer coaching and discussion (see Appendix H). Each caregiver was 

provided approximately five- to eight minutes to discuss their child, what target behavior they 

were working on, and what strategies they used in their practice. Caregivers were then provided 

an opportunity to ask the group questions to seek support about their plan and their child’s target 

behavior. During this time, the interventionist facilitated the discussion, including sharing an 

outline of the 2-hour session, keeping track of time to ensure each caregiver got to speak during 

their allotted time, answering questions that could not be answered by participants, and 

redirecting consultees when off-track.  

The sixth session consisted of an individual meeting conducted virtually via Zoom and 

lasted approximately one hour. The primary objective of this session was to review each 

caregiver’s individual behavior plan (developed during session four) and evaluate its 

66 

 
 
 
 
effectiveness and adjust accordingly. The method for data collection included tracking frequency 

and/or duration of the target behaviors, collected by the caregiver. The consultant and caregiver 

reviewed this datasheet and discussed how well the plan was working or not working, using the 

data to guide the conversation. Any necessary modifications to the plan were made based on data 

tracking the child's problem behavior and progress in acquiring new skills. The session also 

involved a review of pertinent skills covered in previous sessions. Anticipated barriers related to 

the implementation of the behavior plan were discussed, and proactive strategies to overcome 

these challenges following the intervention were explored. 

Overall, the six sessions of the adapted C-HOPE program aimed to address the needs of 

children with suspected autism and their caregivers, combining online modules, individual and 

group sessions, and a range of behavioral strategies.  

Table 3 

Target Behaviors and Intervention Strategies  

Participants 

Target Behavior 

BIP Strategies 

Participant 1 

School Refusal 

Participant 2 

Sibling Conflict 

Token economy 
reinforcement system; visual 
schedule; positive 
reinforcement; offering 
choices 

Differential reinforcement; 
planned ignoring, 
consequence procedures; 
problem-solving flowchart; 
perspective taking sentence 
starters; positive 
reinforcement 

67 

 
 
 
 
 
 
Table 3 (cont’d) 

Participant 3 

Non-Compliance 

Participant 4 

Tantrums 

Participant 5 

Non-Compliance 

Participant 6 

Negative Self-Talk 

Participant 7 

Difficulty with transitions 

Token economy 
reinforcement system; 
differential reinforcement; 
First/then system; positive 
reinforcement 

Differential reinforcement; 
planned ignoring, coping 
strategy toolbox; positive 
reinforcement 

Token economy 
reinforcement system; 
positive reinforcement 

Token economy 
reinforcement system; 
positive reinforcement 

First/then visual schedule; 
positive reinforcement 

Note: BIP = Behavior Intervention Plan  

Interventionists 

The interventionists in the study were two master’s-level clinicians in a school 

psychology doctoral program. The first interventionist was trained by the PI of the study and ran 

groups one and two. The second interventionist was the PI and ran group three. The second PI 

was trained on the COMPASS framework and met with, and received approval from, the 

developer before using the intervention.  

Changes from Proposed Procedures 

Changes to the modality of the intervention were added. The third group transitioned to a 

fully virtual format due to the PI’s relocation from Michigan to Maryland, which made in-person 

sessions in Michigan unfeasible. Recruitment efforts spanned both states; however, all enrolled 

68 

 
 
 
 
participants were based in Maryland. Participants in group three expressed that in-person 

attendance was challenging due to family and work commitments and specifically requested that 

the intervention be delivered entirely virtually to accommodate their schedules. The shift to 

virtual format did not result in any changes to intervention content.  

69 

 
 
 
 
Table 4 

Adapted C-HOPE Intervention 

Session  Session Type  Time 

Session Focus 

1 

2  

3 

4 

5 

6 

Pre-recorded 
online module 

• Overview of C-HOPE and its goals, assessment, and initial goal identification using the 

30 min 

COMPASS profile (behavior domain) 

Pre-recorded 
online module 

30 min 

reactive strategies, and teaching strategies 

• Introduction of a relaxation strategy and wellness component 

• Direct education on principles of behavior (ABCs) and learning as well as proactive, 

Group* 
In-person for 
groups 1 and 2; 
Virtual for group 3 

2hr 

• Discussion of teaching strategies, and positive behavior approaches to prevent 

disruptive behaviors, teach new skills, and respond effectively 

• Discussion of parents and caregivers as essential “environmental supports” for the 
child, parenting expectations, and transitions. A “wellness” package of activities 
designed to identify strategies for self-care and relaxation is reviewed 

Individual* 
In-person for 
groups 1 and 2; 
Virtual for group 3 

Group* 
In-person for 
groups 1 and 2; 
Virtual for group 3 

1hr 

• Identify the disruptive behavior. 
• Development of the child’s behavior plan using the COMPASS framework. Once the 
behavior is identified (to decrease), the replacement skill(s) is created (to increase) 
• Tailored discussion of teaching strategies, and positive behavior approaches to prevent 

disruptive behaviors, teach new skills, and respond effectively 

2hr 

• Problem-solving and reflection with peer-to-peer coaching 

Individual* 
Virtual via zoom 

1hr  

• Review of the individual behavior plan and how it is working. Modifications to the plan 

may occur based on data tracking the child’s problem behavior and new skills 
• Skills are reviewed. Progress toward the goals is reviewed and modifications are 

implemented. Barriers that might arise related to the behavior plan are discussed as well 
as proactive strategies to overcome these issues following the intervention 

*Note: individual means clinician met with caregiver one-one-one, while group means clinician and all caregivers met together  

70 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
Table 5 

Original vs Adapted C-HOPE Procedures 

Session 

Session 
Type 

Time 

Original C-HOPE 

Session Content 

1 

Individual  1hr 

•  Overview of C-HOPE and its 
goals, assessment, and initial 
goal identification using the 
COMPASS profile 

Session 
Type 

Time 

Group 1 & 2 
Pre-recorded 
online 
module 

30 
min 

Group 3 
Virtual 

Adapted C-HOPE 

Session Content  

•  Overview of C-HOPE and its goals, 

assessment, and initial goal 
identification using the COMPASS 
profile 

• 

Introduction of parents and 
their child to the group based 
on an assessment of social, 
communication, and other 
behaviors.  

2 

Group  2hr 

•  Discussion of unique and 

Group 1 & 2 
Pre-recorded 
online 
module 

common characteristics of each 
child.  

•  Overview of theories of autism 

Group 3 
Virtual 

30 
min 

•  Direct education on principles of 
behavior (ABCs) and learning as 
well as proactive, reactive strategies, 
and teaching strategies 
•  Relaxation Strategies  

3 

Group  2hr 

•  Direct education on principles 
of behavior and learning as 
well as proactive and reactive 
strategies 

Group 1 & 2 
Group 
In-person 

2hr 

•  Discussion of teaching strategies, 

and positive behavior approaches to 
prevent disruptive behaviors, teach 
new skills, and respond effectively 

71 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
Table 5 (cont’d) 

4 

Individual  1hr 

5 

Group  2hr 

6 

Group  2hr 

Group 3  
Virtual 

•  Development of the child’s 
personalized behavior plan 
using the COMPASS 
framework. Once the disruptive 
behavior is identified (behavior 
to decrease), the replacement 
skill(s) is generated (behavior 
to increase) 

Group 1 & 2 
Individual 
In-person 

1hr 

Group 3  
Virtual 

•  Discussion of teaching 
strategies and, positive 
behavior approaches to prevent 
disruptive behaviors, teach new 
skills, and respond effectively 

Group 1 & 2 
Group 
In-person  

2hr 

Group 3  
Virtual 

•  Discussion of caregivers as 
essential “environmental 
supports” for the child and the 
emotions associated with the 
diagnosis, parenting 
expectations, and transitions.  

All groups  
virtual  

1hr 

72 

•  Discussion of caregivers as essential 
“environmental supports” for the 
child and the emotions associated 
with the diagnosis, parenting 
expectations, and transitions.  
•  A “wellness” package of activities 

for self-care and relaxation  

Identify the disruptive behavior. 

• 
•  Development of the child’s 

personalized behavior plan using the 
COMPASS framework. Once the 
disruptive behavior is identified 
(behavior to decrease), the 
replacement skill(s) is generated 
(behavior to increase) 

•  Problem-solving and reflection with 

peer-to-peer coaching 

•  Review of the individual behavior 
plan and how it is working.  
•  Modifications to plan as needed 
•  Skills taught in sessions one through 

five are reviewed 

•  Anticipated barriers that might arise 
related to the implementation of the 
behavior plan are discussed 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Table 5 (cont’d) 

7 

Individual  1hr 

8 

Individual 
Session 

1hr 

•  A “wellness” package of 
activities for self-care and 
relaxation  

•  Review of the individual 

behavior plan and how it is 
working.  

•  Modifications to plan as 

needed 

•  Skills taught in sessions one 
through five are reviewed  
•  Anticipated barriers that might 

arise related to the 
implementation of the behavior 
plan are discussed  

N/A 

N/A 

N/A 

N/A 

N/A 

N/A 

73 

 
 
 
 
 
 
 
 
 
 
 
 
Incentive  

Caregivers were offered a free parent training program. It was the PI’s hope that a free 

parent training program was incentivizing to caregivers because there are limited-to-no free 

services provided to families on the evaluation waiting list for autism concerns. Additionally, the 

parent training program was brief and offered across multiple modalities, which the PI hoped 

would increase accessibility to the program as it allowed more families to participate without the 

potential burden of traveling to each session,  

Ethical Considerations 

Data collection for the current study was approved by the Human Research Protection 

Program at MSU (HRPP/IRB STUDY00010147) and conducted with the approved procedures. 

Before enrolling in the study, participants were briefed on the study’s purposes, procedures, and 

their role in the study. Once enrolled, participants received a numerical ID number. The data file 

containing all participant information, survey responses, and data collected through the survey 

was deidentified—with only the numerical ID code for identification that did not link protected 

health information (PHI; birthday, age, name, etc.). A code key linking participant information to 

their deidentified numerical ID was created and stored in an additional password-protected file. 

This code key was stored separately from the data, in a password-protected file, and will be 

discarded three years after the completion of the study. 

All electronic information and data obtained was stored on Qualtrics, accessible only 

through a secure password-protected computer. In addition, electronic consent forms were stored 

in a separate encrypted folder away from the code key so that the researchers cannot link the 

participants' names to their data. Only the principal investigator and their advisor were allowed 

74 

 
 
 
 
 
access to the data. Research records will be retained for at least five years after the completion of 

the research study.  

Given the content of the measures, it was possible that some participants may have found 

some of the items distressing. Additionally, some participants may have felt fatigued due to the 

time involved in filling out the responses. If either of these instances occurred, participants were 

informed that they could skip any question they did not feel comfortable answering or come back 

to complete items later before they submitted them. No caregivers reported experiencing distress 

or fatigue in filling out the measures.  

Participant Recruitment and Attrition   

The participant recruitment strategy incorporated oversampling to accommodate potential 

participant drop-out. Despite this, the PI encountered challenges in recruiting families and 

attrition occurred across groups one through three. The PI encountered difficulty in both 

identifying recruiting families that met the eligibility criteria and in engaging those who 

expressed initial interest. Several families who showered interest did not enroll in the 

intervention. Due to insufficient recruitment, the principal investigator opted to proceed with 

smaller sample sizes, as efforts to enroll additional participants were unsuccessful. Furthermore, 

several families withdrew from the intervention as detailed below.  

Group One 

 Three participants withdrew from the intervention (50% of Group 1). One participant 

withdrew at session 2, and another at session five, both due to family conflicts. One participant 

dropped out without offering a reason at session five.   

75 

 
 
 
 
 
Group Two 

Two participants withdrew from the intervention (50% of Group 2). One participant 

withdrew at session four due to conflicting demands. Another participant withdrew at session 

three without offering a reason. 

Group Three 

Zero participants withdrew from the intervention.  

Data Analysis  

Statistical analyses were completed using IBM SPSS Statistics – Version 28 (IBM Inc., 

2021, including descriptive and inferential statistics. Sample characteristics were summarized 

using means and standard deviations for continuous measures or frequencies and percentages for 

categorical measures.  

Analysis for Primary Research Questions 

1.  Research Question 1: Do caregivers show a pre-post difference in caregiver stress 

after participating in the C-HOPE intervention?  

2.  Research Question 2: Do caregivers show a pre-post difference in caregiver self-

efficacy after participating in the C-HOPE intervention?  

3.  Research Question 3: Do caregivers show a pre-post difference in parent knowledge 

about parent training and supportive strategies after participating in the C-HOPE 

intervention? 

4.  Research Question 4: Do caregivers show a pre-post difference in child behavior 

problem after participating in the C-HOPE intervention?  

Multiple dependent samples t-tests were conducted to examine whether participation in 

the C-HOPE intervention resulted in a statistically significant changes in caregiver stress levels, 

76 

 
 
 
 
 
 
as measured by the PSI-4 SF, caregiver self-efficacy, as measured by the BPS, caregiver 

knowledge about training and supportive strategies, as measured by the PKQ, and child behavior 

intensity, as measured by the ECBI, among caregivers awaiting an autism diagnosis. Due to the 

small sample size and to ensure adequate statistical power, multiple dependent samples t-tests 

were conducted instead of repeated measures Analysis of Variance (ANOVAs) as originally 

planned.  

The assumptions of the multiple dependent samples t-tests were evaluated. The 

assumption of normality of the difference scores (population from which the sample was drawn 

is normally distributed), the assumptions of homogeneity of variance, and independence of 

observations (i.e., the data were independent) were met. Upon meeting these assumptions, five 

dependent samples t-tests were conducted to compare all study variables (PSI-4 SF Total Stress 

Scale, BPS Self-Efficacy, BPS Satisfaction, PKQ Total Score, and ECBI Intensity Scale) from 

pre- to post-intervention.  

To protect from type I error, a Bonferroni correction was conducted. The Bonferroni 

correction is a commonly used method to adjust the significance level (i.e., alpha level) in 

hypothesis testing when multiple comparisons are made simultaneously. When one conducts 

multiple statistical tests such as an t-Tests, the likelihood of obtaining a significant result by 

chance alone increases. The Bonferroni correction reduces this risk by dividing the desired alpha 

level (typically 0.05) by the number of tests being performed. This adjusted alpha level is then 

used as the new threshold for statistical significance. In the current study, the alpha was divided 

by 5 (0.05/5), which resulted in an adjusted alpha of 0.01.  

Effect sizes were calculated using Cohen’s dz (Cohen, 1988) by conducting the following 

equation - Mean difference (Mean two – Mean one)/Standard Deviation of difference scores. A 

77 

 
 
 
 
small effect is 0.20, a medium effect is 0.50, and a large effect is 0.80. Given the modest sample 

size, Hedges’ g (Hedges & Olkin, 1985) was also computed as a bias-corrected estimate of the 

effect size dz. Hedges’ g was calculated using dz x (1 – (3/4n-5). This correction is useful in 

small samples to provide a more accurate estimate of the population effect. Finally, Cohen’s d 

(Cohen, 1988) was calculated to compare effects from the current study to previous research on 

C-HOPE given that the other studies reported Cohen’s d over Cohen’s dz. Interpretation of the 

effect size d parallel those for Cohen’s dz (i.e., small, medium, and large). Cohen’s d was 

calculated using d = (M1 – M2)/SDpooled.  

An Influential Case Analysis (ICA) was conducted using the Leave One Out (LOO) 

technique, also referred to as the jackknife method (Quenouille 1956; Tukey 1958; Miller 1974; 

Efron 1982), to assess whether any individual data point disproportionality influenced the results. 

This technique involved iteratively removing one case from the dataset at a time. For each 

iteration, the model is refitted using the remaining datapoints (n-1 observation). The t-test is re-

run, and the output is reviewed for substantial changes in test statistics, effect sizes, and 

statistical significance. If a single observation causes significant changes, it is considered an 

influential case. 

Analysis for Secondary Research Question: Caregiver Perceptions of the Intervention 

Research Question 5. How do families perceive the acceptability of the intervention, 

intervention appropriateness, and feasibility of the intervention, as measured by a post-

intervention rating scale and focus group?  

First, means and standard deviations were computed from the administration of the 

AIM/IAMFIM measure at post-treatment. Next, to complement the descriptive analysis of 

quantitative data, a qualitative analysis of the focus group data was conducted using thematic 

78 

 
 
 
 
analysis (Braune & Clark, 2006). Braun and Clarke's (2006) thematic analysis is a widely used 

qualitative research method for identifying and analyzing patterns within qualitative data. It 

involves a systematic and iterative process of data coding and theme development.  

First, the principal investigator familiarized themselves with the data by transcribing the 

audio tapes. They then read and re-read the transcriptions to gain a comprehensive understanding 

of the content. Then, codes, which are short labels or tags that capture specific concepts within 

the data, were generated. These codes were applied to segments of the text that related to the 

identified features. Through a process of constant comparison and refinement, codes were 

organized into potential themes, which represent patterns of meaning across the data. These 

themes were reviewed and refined to ensure they accurately captured the essence of the data, and 

a thematic map was created to visualize the relationships between themes. A second coder (i.e., a 

school psychology doctoral student) completed the same steps simultaneously. The PI and the 

second coder met to discuss findings and arrived at consensus when codes did not align. The 

final step involved writing a report that summarized the key findings and illustrated the themes 

with quotations from the participants. 

79 

 
 
 
 
RESULTS 

Preliminary analyses were conducted using frequency tables and histograms to screen the 

data for normality and outliers. Skewness and kurtosis values fell within acceptable ranges (±2; 

George & Mallery, 2010), indicating no significant deviations from normality. Two cases were 

identified as potential outliers when reviewing the ECBI data. At pre-test, cases six and seven 

reported t-scores in the 80-range, while all other participants’ t-scores fell within the range of 59 

to 64. At post-test, cases six and seven reported t-scores in the 70-range, while all other 

participants’ scores fell within the range of 52 to 55 t-scores. Given the small sample size, they 

are included in the analyses to preserve statistical power. Their potential influence will be 

considered when interpreting the findings in the discussion. No other potential outliers were 

detected.  

Descriptives 

Descriptive statistics, including means and standard deviations, were calculated for each 

variable at both pre- and post-intervention stages. To examine the strength and direction of the 

relationship in pre- and post-intervention scores for each variable, a series of Pearson 

correlations were conducted. Scores range from -1 to 1, with -1 indicating a negative correlation, 

0 representing no correlation, and 1 representation a positive correlation (Schober et al., 2018). 

Correlation coefficients 0 to 0.10 are negligible, coefficients 0.10 to 0.39 are weak correlations, 

0.40 – 0.69 are moderate correlations, 0.80 to 0.89 are strong correlations, and 0.90 to 1.00 are 

very strong correlations (Schober et al., 2018). When looking at the Pearson correlation, there 

was a weak correlation between pre- to post-scores for the PKQ and BPS satisfaction measures, 

moderate correlation for the BPS efficacy and PSI-4 SF measures, and very strong correlation for 

the ECBI intensity measure. The Pearson correlation helps explore the relationship between each 

80 

 
 
 
 
construct from pre- to post-intervention and assess whether there were changes across time. If 

changes are observed, it can be suggested that the intervention provided some level of that 

change. See Table 6.  

Table 6 

Descriptive Statistics  

Variable 

Post (N = 7) 
SD 
M 
9.23 
59.29 
5.83 
33.43 
12.47 
30.57 
5.38 
62.71 
8.96 
59.00 

Pre (N = 7) 
SD 
M 
9.10 
37.14 
5.88 
23.43 
8.27 
25.00 
6.60 
68.57 
9.83 
67.29 

r pre-post 
.26 
.26 
.54 
.63 
.97 

p-value of r 
.58 
.58 
.21 
.13 
<.001 

PKQ 
BPS Satisfaction 
BPS Efficacy 
PSI-4 SF Total 
ECBI Intensity 
Note. PKQ = The Parent Knowledge Questionnaire (Dahiya et al., 2021) uses raw scores ranging 
from 17 to 68, with higher scores suggestions higher knowledge. BPS = Being a Parent Scale 
(Johnston and Mash 1989) uses raw scores with a range of 10 to 60 for efficacy and 6 to 36 for 
satisfaction, with higher scores suggestions higher efficacy and satisfaction with caregiving. PSI-
4 SF = The Parenting Stress Index – fourth edition, short form (Abidin, 2012) uses T-scores and 
is norm-referenced, with a mean (M) of 50 and a standard deviation (SD) of 10; scores range 
from 20 to 100 where scores below 62 are within normal limits, scores 63-64 are borderline 
levels of stress, scores 65-66 are clinically significant levels of stress, and scores about 67 are 
clinically severe levels of stress. ECBI = The Eyberg Child Behavior Inventory (Eyberg 
and Pincus 1999) uses T-scores and is norm-referenced, with a mean (M) of 50 and a standard 
deviation (SD) of 10; scores range from 20 to 100, with scores ≥60 indicating clinically 
significant problem behavior. p-values represent one-tailed tests.  

Main Analyses  

Research Question 1  

Do caregivers, who are waiting for an autism diagnostic evaluation for their child and 

participate in the C-HOPE intervention, show a pre-post difference in caregiver stress 

immediately after participating in the C-HOPE intervention, as measured by the Parental Stress 

Index-Fourth Edition Short Form (PSI-4 SF; Abidin 2012)?    

81 

 
 
 
 
 
 
 
The assumptions of the t-test were met, including independence of observations, 

normality of data, homogeneity of variances, and random sampling. A dependent samples t-test 

was conducted to compare caregiver reported scores on the PSI-4 SF Total Stress Score at pre-

and post-intervention. The results indicate that parent total stress levels were significantly lower 

following the program, t (6) = -2.96, p = .01, d = .92, dz = -1.12, gz = -.97. This reduction 

reflects a large effect according to Cohen's (1988) guidelines and a large effect according to 

Hedges’ (1981) guidelines. On average, caregivers’ total stress scores decreased from M = 

68.57, SD = 6.60 at pre-test to M = 62.71, SD = 5.38 at post-test.  

Supplemental Analysis. An Influential Case Analysis (ICA) was conducted using the 

Leave One Out (LOO) technique, also referred to as the jackknife method (Quenouille 1956; 

Tukey 1958; Miller 1974; Efron 1982), to assess whether any individual data point 

disproportionality influenced the results. This technique involved iteratively removing one case 

from the dataset at a time. For each iteration, the t-test was repeated using the remaining 

datapoints (n-1 observation). The t-test was re-run and the output were reviewed for substantial 

changes in test statistics, effect sizes, and statistical significance. If a single observation causes 

significant changes, it was considered an influential case. No case was considered influential. 

See Table 7 for the ICA. 

When looking at each participant, the pre- to post-intervention stress scores revealed 

differences among participants. T-sores of <62 are within the normal range, t-scores of 63 – 64 

are in the borderline range, scores 65-66 are in the clinically significant range, and scores >67 are 

in the clinically severe range. Three out of seven participants (43%) scores moved from the 

clinically significant range to the elevated range. Two out of seven participants (29%) stayed in 

the elevated stress range from pre- to post-intervention. One out of seven participants (14%) had 

82 

 
 
 
 
elevated scores at pre-intervention and scores within the normal range at post-intervention. One 

out of seven participants (14%) stayed in the normal stress range from pre- to post-intervention. 

Table 7  

t-test for Parent Stress Index-Fourth Edition, Short Form – Total Score 

N (df)  Mdiff  SDdiff 

t 

p 

Cohen’s dz 
(95% CI) 

7 (6) 

-5.86  5.24 

-2.96 

.01* 

-1.12 (-2.06 – -.13) 

Hedge’s g 
Corrected dz 
(95% CI) 
-.97 (-1.79 – -.11) 

Participant 
Case 
Removed 
N/A 

Inferential Case Analysis - Leave One Out Technique 

.02* 
.03* 
.02* 
.02* 
.02* 
.02* 
.03* 

-2.78 
-2.37 
-2.66 
-2.89 
-3.35 
-2.78 
-2.57 

-6.33  5.57 
-5.18  5.18 
-6.17  5.67 
-4.33  3.67 
-6.87  4.99 
-6.33  5.57 
-6.00  5.23 

-.96 (-1.82 – -.05) 
-.81 (-1.62 – -.04) 
-.91 (-1.76 – -.20) 
-.99 (-1.87 – -.68) 
-1.15 (-2.09 – -.16) 
-.96 (-1.82 – -.05) 
-.88 (-1.71 – -.001) 

-1.14 (-2.16 – -.05) 
-0.97 (-1.93 – -.50) 
-1.09 (-2.09 – -.02) 
-1.18 (-2.22 – -.81) 
-1.37 (-2.49 – -.19) 
-1.14 (-2.16 – -.05) 
-1.05 (-2.04 – -.001) 

6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
Note: Mdiff is the mean of the difference scores; SDdiff is the standard deviation of the difference 
scores. PSI-4 SF = The Parenting Stress Index, fourth edition – short form (Abidin, 2012) uses 
T-scores and is norm-referenced, with a mean (M) of 50 and a standard deviation (SD) of 10; 
scores range from 20 to 100 where scores below 62 are within normal limits, scores 63-64 are 
borderline levels of stress, scores 65-66 are clinically significant levels of stress, and scores 
about 67 are clinically severe levels of stress. 
*Significant at .05 and at .01 (Alpha Correction, Bonferroni). 
p-values represent one-tailed tests because direction was specified based on anticipated impact of 
the parent training program 

Case 1 
Case 2 
Case 3 
Case 4 
Case 5 
Case 6 
Case 7 

Research Question 2 

Do caregivers, who are in the process of obtaining an autism diagnosis for their child and 

participate in the C-HOPE intervention, show a pre-post difference in caregiver self-efficacy and 

satisfaction immediately after undergoing the C-HOPE intervention, as measured by the Being 

a Parent Scale (BPS; Johnston and Mash 1989)?     

The assumptions of the t-test were met, including independence of observations, normality of 

data, homogeneity of variances, and random sampling. A dependent samples t-test was 

83 

 
 
 
 
 
conducted to compare caregiver reported scores on the BPS Efficacy and Satisfaction scales at 

pre-intervention post-intervention.  

Satisfaction. The results from the pre-test (M = 23.43, SD = 5.88) and post-test 

(M =33.43, SD = 5.83) indicate that caregiver satisfaction was significantly higher following the 

program, t(6) = 3.71, p = .005, , d = 1.48, dz =1.14, gz = 1.22. This reduction reflects a large 

effect according to Cohen's (1988) guidelines and a large effect according to Hedges’ (1981) 

guidelines. These results support the hypothesis that caregivers participating in the C-HOPE 

parent training program would experience increased satisfaction immediately following the 

program.  

Efficacy. The results of significance testing comparing the pre-test (M = 25.00, SD = 8.27) 

and post-test (M =30.57, SD = 12.47) indicate caregiver efficacy was not significantly higher 

following the program, t (6) = 1.39, p = .108, d = .61, dz = .52, gz = .46. These results did not 

support the hypothesis that caregivers participating in the C-HOPE parent training program 

would experience increased efficacy immediately following the program. While the test of 

significance did not support the hypothesis, effect size calculations reflect a medium effect 

according to Cohen's (1988) guidelines and a medium effect according to Hedges’ (1981) 

guidelines. The medium effect suggests that the sample may have not been large enough to 

detect a significant difference, but there is meaningful change reported overall.  

Supplemental Analyses. An Influential Case Analysis was conducted using the Leave One 

Out (LOO) technique, also referred to as the jackknife method (Quenouille 1956; Tukey 1958; 

Miller 1974; Efron 1982), to assess whether any individual data point disproportionality 

influenced the results (previously described in RQ1). On the Satisfaction scale, no influential 

cases were identified. Similarly, no cases were considered influential on the Efficacy scale; 

84 

 
 
 
 
however, case three approached the threshold for significance and warrants cautious 

interpretation. See Tables 8 and 9 for the ICA.  

When examining each participant's scores, six out of seven participants (86%) showed 

increased satisfaction scores from pre- to post-intervention. Additionally, four participants (57%) 

had increased efficacy scores, two participants (29%) had decreased efficacy scores, and one 

participant (14%) did not show any change in efficacy scores from pre- to post-intervention. 

Interpretive ranges are not provided by the developers of the BPS, however, increased scores 

demonstrated increased caregiver efficacy and caregiver satisfaction.  

Table 8  

t-test for Being a Parent Scale - Satisfaction  

N 
(df) 

Mdiff  SDdiff 

t 

p 

Cohen’s dz 
(95% CI) 

7 (6)  10.00 

7.14 

3.71 

.005* 

1.40 (.30 – 2.45) 

Hedge’s g 
Corrected dz 
(95% CI) 
1.22 (.26 – 2.12) 

Participant 
Case 
Removed 
N/A 

Inferential Case Analysis - Leave One Out Technique 

7.58 
7.58 
9.35 
7.81 
6.81 
7.58 

.001* 
.009* 
.009* 
.014* 
.027* 
0.03* 
0.03* 

2.28 (3.85 – 6.77) 
1.41 (.21 – 2.54) 
1.41 (.21 – 2.54) 
1.25 (.12 – 2.32) 
1.26 (.13 – 2.33) 
1.27 (.14 – 2.35) 
1.23 (.11 – 2.29) 

6 (5)  12.00  12.14  4.57 
3.45 
6 (5)  10.67 
3.45 
6 (5)  10.67 
3.07 
8.83 
6 (5) 
3.09 
9.83 
6 (5) 
1.53 
8.67 
6 (5) 
6 (5) 
1.40 
9.33 
Note: Mdiff is the mean of the difference scores; SDdiff is the standard deviation of the difference 
scores. BPS = Being a Parent Scale (Johnston and Mash 1989) uses raw scores with a range of 6 
to 36 for satisfaction, with higher scores suggesting higher satisfaction with caregiving. 
*Significant at .05 and at .01 (Alpha Correction, Bonferroni). 
p-values represent one-tailed tests because direction was specified based on anticipated impact of 
the parent training program. 

1.92 (.67 – 3.85) 
1.18 (.18 – 2.14) 
1.18 (.18 – 2.14) 
1.05 (.10 – 1.95) 
1.06 (.11 – 1.96) 
1.07 (.11 – 1.98) 
1.04 (.09 – 1.93) 

Case 1 
Case 2 
Case 3 
Case 4 
Case 5 
Case 6 
Case 7 

85 

 
 
 
 
 
 
 
Table 9  

t-test for Being a Parent Scale – Efficacy  

N 
(df) 

Mdiff 

SDdiff 

t 

p 

Cohen’s dz 
(95% CI) 

7 (6) 

5.57 

10.64 

1.39 

.108 

.52 (-.29 – 1.30) 

Hedge’s g 
Corrected dz 
(95% CI) 
.46 (-.25 – 1.13) 

Participant 
Case 
Removed 
N/A 

Inferential Case Analysis - Leave One Out Technique 

1.27 
1.64 
1.80 
.830 
.830 
1.16 
1.40 

6.00 
7.17 
7.50 
3.17 
3.17 
5.50 
6.50 

.261 
.081 
.066 
.222 
.222 
.300 
.110 

11.59 
10.70 
10.23 
9.35 
9.35 
11.66 
11.34 

.52 (-.36 – 1.36) 
.67 (-.25 – 1.54) 
.73 (-.21 – 1.62) 
.34 (-.50 – 1.15) 
.34 (-.50 – 1.15) 
.47 (-.39 – 1.30) 
.57 (-.32 – 1.42) 

6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
Note: Mdiff is the mean of the difference scores; SDdiff is the standard deviation of the difference 
scores. BPS = The Being a Parent Scale (Johnston and Mash 1989) uses raw scores with a range 
of 10 to 60 for efficacy, with higher scores suggestions higher efficacy with caregiving. 
*Significant at .05 and at .01 (Alpha Correction, Bonferroni).  
p-values represent one-tailed tests because direction was specified based on anticipated impact of 
the parent training program. 

.44 (-.31 – 1.14) 
.56 (-.21 – 1.29) 
.62 (-.18 –1.36) 
.28 (-.42 – .97) 
.28 (-.42 – .97) 
.40 (-.33 – 1.09) 
.48 (-.27 – 1.19) 

Case 1 
Case 2 
Case 3 
Case 4 
Case 5 
Case 6 
Case 7 

Research Question 3  

Do caregivers, who are in the process of obtaining an autism diagnosis for their child and 

participate in the C-HOPE intervention, show a pre-post difference in parent knowledge about 

parent training and supportive strategies immediately after undergoing the C-HOPE 

intervention, as measured by the Parent Knowledge Questionnaire (PKQ; Dahiya et al., 2021)?  

The assumptions of the t-test were met, including independence of observations, normality of 

data, homogeneity of variances, and random sampling. A dependent samples t-test was 

conducted to compare caregiver reported scores on the PKQ at pre-intervention and post-

intervention. The results from the pre-test (M = 37.14, SD = 9.09) and post-test (M = 49.29, SD = 

9.23) indicate that caregiver knowledge about behavioral principles were significantly higher 

following the program, t(6) = 5.24, p = <.001, d = 2.13, dz = 1.98, gz = 1.72.  This reduction 

86 

 
 
 
 
 
reflects a large effect according to Cohen's (1988) guidelines and a large effect according to 

Hedges’ (1981) guidelines. 

Supplemental Analyses. An Influential Case Analysis was conducted using the Leave 

One Out (LOO) technique, also referred to as the jackknife method (Quenouille 1956; Tukey 

1958; Miller 1974; Efron 1982), to assess whether any individual data point disproportionality 

influenced the results (described in RQ1). No influential cases were identified. See Table 10 for 

the ICA.  

When examining each participant's scores, all seven participants (100%) showed 

increased parent knowledge about behavioral principles taught in the parent training program 

from pre- to post-intervention. No interpretive ranges are provided by the developers of the 

PKQ; however, increased scores demonstrate increased knowledge about the material taught in 

the parent training program.  

Table 10  

t-test for Parent Knowledge Questionnaire  

N (df)  Mdiff  SDdiff 

t 

p 

Cohen’s dz 
(95% CI) 

Hedge’s g 
Corrected dz 
(95% CI) 

7 (6) 

22.14  11.17  5.24  <.001*  1.98 (.64 – 3.28)  1.72 (.56 – 2.85) 

Inferential Case Analysis - Leave One Out Technique 

6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 
6 (5) 

.003* 
.004* 

22.67  12.14  4.72 
20.83  11.63  4.39 
25.00  9.01 
24.17  10.74  5.51 
21.33  12.01  4.35 
21.00  11.78  4.37 
20.00  10.54  4.31 

1.87 (.46 – 3.22)  1.57 (.39 – 2.71) 
1.79 (.42 – 3.12)  1.50 (.36 – 2.61) 
6.80  <.001*  2.77 (.92 – 4.60)  2.33 (.77 – 3.87) 
2.25 (.66 – 3.80)  1.89 (.56 – 3.19) 
1.78 (.42 – 3.08)  1.49 (.35 – 2.59) 
1.78 (.42 – 3.09)  1.50 (.35 – 2.60) 
1.90 (.48 – 3.26)  1.60 (.40 – 2.74) 

.001* 
.004* 
.004* 
.003* 

Participant 
Case 
Removed 
N/A 

Case 1 
Case 2 
Case 3 
Case 4 
Case 5 
Case 6 
Case 7 

Note: Mdiff is the mean of the difference scores; SDdiff is the standard deviation of the difference 
scores. PKQ = The Parent Knowledge Questionnaire (Dahiya et al., 2021) uses raw scores 
ranging from 17 to 68, with higher scores suggestions higher knowledge. 
*Significant at .05 and at .01 (Alpha Correction, Bonferroni)  
p-values represent one-tailed tests because direction was specified based on anticipated impact of 
the parent training program. 

87 

 
 
 
 
 
 
Research Question 4  

Do children of caregivers, who are in the process of obtaining an autism diagnosis for 

their child and participate in the C-HOPE intervention, show a pre-post difference in child 

behavior intensity immediately after their caregivers participate in the C-HOPE intervention, as 

measured by the Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus 1999)?    

The assumptions of the t-test were met, including independence of observations, normality of 

data, homogeneity of variances, and random sampling. A dependent samples t-test was 

conducted to compare caregiver reported scores on the ECBI Intensity Scale at pre-intervention 

post-intervention. The results from the pre-test (M = 67.29, SD = 8.83) and post-test (M = 

59.00, SD = 8.96) indicate that child problem behavior intensity was significantly lower 

following the program, t(6) = -29.14, p = <.001, d = .83, dz = -3.96, gz = -3.44. This reduction 

reflects a large effect according to Cohen's (1988) guidelines and a large effect according to 

Hedges’ (1981) guidelines. 

Supplemental Analyses. An Influential Case Analysis was conducted using the Leave 

One Out (LOO) technique, also referred to as the jackknife method (Quenouille 1956; Tukey 

1958; Miller 1974; Efron 1982), to assess whether any individual data point disproportionality 

influenced the results (described in RQ1). No influential cases were identified. See Table 11 for 

the ICA.  

Participants’ individual scores were also examined. Five out of seven participants (71%) 

reported a reduction in child behavior problem intensity scores that constituted clinically 

significant scores (i.e., ≥60) at pre-intervention to non-clinically significant scores (i.e., ≤60) at 

post-intervention. The other two participants (29%) reported a reduction in child behavior 

88 

 
 
 
 
 
problem intensity; however, they did not report scores below the clinically significant threshold 

(i.e., t-score ≥60). 

Table 11  

t-test for ECBI – Intensity Scale 

Mdiff 

SDdiff 

t 

p 

N 
(df) 

7 (6) 

-29.14 

7.36 

-10.48  <.001* 

Cohen’s dz  
(95% CI) 

-3.96  
(-6.25 – -1.66)  

Hedge’s g 
Corrected dz 
(95% CI) 
-3.44  
(-5.43 – -1.44)  

Participant 
Case 
Removed 
N/A  

6 (5) 

-28.50 

6 (5) 

-28.83 

6 (5) 

-31.33 

6 (5) 

-28.17 

6 (5) 

-30.17 

6 (5) 

-29.17 

6 (5) 

-27.83 

4.97 

7.84 

8.01 

-8.82  <.001* 

-8.90  <.001* 

-15.45  <.001* 

Inferential Case Analysis - Leave One Out Technique 
-3.06 
(-4.99 – -1.10) 
-3.04 
(-4.95 – -1.09) 
-5.30 
(-8.56 – -2.08) 
-3.14 
(-5.13 – -1.14) 
-3.38 
(-5.52 – -1.25) 
-3.04 
(-4.98 – -1.10) 
-3.29 
(-5.37 – -1.21) 

-3.64 
(-5.95 – -1.31) 
-3.60 
(-5.89 – -1.30) 
-6.31 
(-10.18 – -2.47) 
-3.73 
(-6.10 – -1.36) 
-4.03 
(-6.56 – -1.49) 
-3.62 
(-5.92 – -1.30) 
-3.91 
(-6.39 – -1.44) 

-9.141  <.001* 

-9.59  <.001* 

-8.86  <.001* 

-9.86  <.001* 

7.55 

7.49 

8.06 

7.11 

Case 1 

Case 2 

Case 3 

Case 4 

Case 5 

Case 6 

Case 7 

Note: Mdiff is the mean of the difference scores; SDdiff is the standard deviation of the difference; 
ECBI = Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999) uses T-scores and is norm-
referenced, with a mean (M) of 50 and a standard deviation (SD) of 10; scores range from 20 to 
100, with scores ≥60 indicating clinically significant problem behavior.  
*Significant at .05 and at .01 (Alpha Correction, Bonferroni)  
p-values represent one-tailed tests because direction was specified based on anticipated impact of 
the parent training program. 

Analyses for Research Question 5 

Research Question 5 

How do families perceive the acceptability of the intervention, intervention 

appropriateness, and feasibility of the intervention, as measured by a post-intervention rating 

scale and focus group?   

89 

 
 
 
 
 
Both quantitative and qualitative data were collected to evaluate participants’ perceptions 

of the parent training program. A quantitative measure was used to measure acceptability, 

feasibility, and intervention appropriateness. A focus group at the end of the program was used 

to understand broader themes of participants’ perceptions of the parent training program, as well 

as feedback for improvement. 

Post Intervention Rating Scale. Acceptability, appropriateness, and feasibility of the 

intervention was measured through the Acceptability of Intervention Measure (AIM), 

Intervention Appropriateness Measure (IAM), & Feasibility of Intervention Measure (FIM).  

Acceptability of Intervention. The item-level mean scores ranged from 4.33 to 4.57, 

indicating that participants perceived all individual-level items of acceptability were high quality, 

as a score of 4 indicates “agree” and a score of 5 indicates “completely agree.” The Acceptability 

of Intervention mean total score was 17, as the highest total score possible on the measure is 20. 

Descriptive statistics for the ratings of acceptability are presented in Table 12.  

Intervention Appropriateness. The item-level mean scores ranged from 4.43 to 4.57, 

indicating that participants perceived all individual-level items of intervention appropriateness 

were high quality, as a score of 4 indicates “agree” and a score of 5 indicates “completely agree.” 

The intervention appropriateness mean total score was 18.86, as the highest total score possible 

on the measure is 20. Descriptive statistics for the ratings of intervention appropriateness are 

presented in Table 12.  

Feasibility of Intervention. The item-level mean scores ranged from 4.14 to 4.71, 

indicating that participants perceived all individual-level items of feasibility were high quality, as 

a score of 4 indicates “agree” and a score of 5 indicates “completely agree.” The feasibility of 

90 

 
 
 
 
intervention mean total score was 18.14, as the highest total score possible on the measure is 20. 

Descriptive statistics for the ratings of feasibility are presented in Table 12.  

Table 12  

Acceptability, Appropriateness, and Feasibility of Intervention  

SD  Min - Max  Mode 
N  M 
Item 
0.52 
4.33 
This Parent Training Program met my approval 
7 
0.53 
4.57 
This Parent Training Program is appealing to me  7 
0.53 
4.57 
7 
I like this Parent Training Program 
0.53 
4.57 
7 
I welcome this Parent Training Program 
2.04 
7 
17 
0.53 
4.43 
7 
0.53 
4.57 
7 
0.53 
4.57 
7 
7 
0.53 
4.57 
7  18.86  1.91 

This Parent Training Program was fitting 
This Parent Training Program was suitable 
This Parent Training Program was applicable 
This Parent Training Program was a good match 
Intervention Appropriateness Total Score 

4 - 5 
4 - 5 
4 - 5 
4 - 5 
16 - 20 
4 - 5 
4 - 5 
4 - 5 
4 - 5 
16 - 20 

4 
5 
5 
5 
16, 20* 
5 
5 
5 
5 
20 

Acceptability of Intervention Total Score 

This Parent Training Program was 
implementable 
This Parent Training Program was possible 
This Parent Training Program was doable 
This Parent Training Program was easy to me 
Feasibility of Intervention Total Score 

7 

4.71 

0.49 

4 - 5 

4.71 
4.57 
4.14 

0.49 
7 
0.53 
7 
7 
0.90 
7  18.14  2.11 

4 - 5 
4 - 5 
3 - 5 
15 - 20 

5 

5 
5 
5 
20 

Note: Scores on the AIM/FIM/IAM (Weiner et al, 2017) are 1 = Completely disagree, 2 = 
Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Completely agree; Total Scores range 
from 4 to 20.  
*Regarding mode, three scores of 16, three scores of 20, and one of 19 were reported. Thus, two 
modes are included in the table. 

Focus Group 

Four independent focus groups were conducted. One was conducted after the completion of 

each group, however, one participant from Group 2 was unable to attend the scheduled focus 

group. To accommodate this, the interventionist conducted an individual interview with that 

participant. After analyzing the focus groups through a thematic analysis, five main themes were 

identified (see Appendix I for codebook): (1) Parent Stress and Emotional Overload (2) Support 

Needs and Access to Resources, (3) Personal Growth and Parenting Journey, (5) Community and 

91 

 
 
 
 
 
Validation, and (5) Program Structure. These themes were derived from the data through a 

process of coding, identifying patterns, and categorizing recurring ideas as outlined in Braun and 

Clarke’s (2006) method.  

Theme 1: Caregiver Stress and Emotional Overload. The first identified theme was 

caregiver emotions and stress. Caregivers described the emotional toll of parenting a child with 

suspected autism while waiting for an evaluation. One caregiver (pseudonyms used) noted, 

“…especially with these there's some waitlists out there that are two and three years long. As a 

parent, you're, like, calling trying to figure out where you're going to put. I mean, it's like a night 

it's really a nightmare, to be honest with you, while you're also managing behaviors." (Charlotte, 

Group 1). This quote captures the emotional stress one caregiver carried with them when they 

joined the program. Many caregivers described the feeling of being on edge, unsupported, or 

exhausted by the systems they must navigate. 

 Stress was also noted to be associated with feelings of neglecting personal well-being 

and self-care. For example, one caregiver reflected, “Yeah, I feel like for me, I didn't realize how 

much I wasn't focusing on myself. I was solely focused on [name of child redacted] and not, you 

know, my own stress. And, you know, I think staying on top of my stress has helped quite a bit.” 

(Fiona, Group 1). This caregiver highlighted that learning stress-reduction techniques and 

finding time to prioritize their well-being supported their emotions and reduced stress. 

Theme 2: Support Needs and Access to Resources. Another theme was the caregivers' 

need for accessible, actionable support, both in terms of emotional and practical resources. 

Broadly, caregivers noted that they needed timely support but there were not many resources 

available to them. For example, "And there's not really a lot offered for people on the wait list. 

Yeah." (Lexis, Group one) 

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Several caregivers noted the need for strategies that were individualized and applicable to 

their child’s daily realties. Caregivers also emphasized the need for strategies that felt tailored 

and realistic. A caregiver noted the need for one-on-one support and practice, such as “I really 

needed something like this. Not just someone telling me to breathe, but showing me what I can 

do with my child.” (Ellis, Group 2). Other caregivers expressed appreciation for structured 

behavioral tools, such as the behavior intervention plan (BIP), with one caregiver noting, 

“Receiving that BIP was very helpful, as far as like I said, sometimes you just need a guide, and 

you don't wanna you're like I said, it's gonna you guys, like, did it. It was one pretty package. 

You're like, here you go.” (Lexis, Group one).  

Theme 3: Personal Growth and the Parenting Journey. Many caregivers described how 

the intervention contributed to their growth as caregivers and individuals. One caregiver shared, 

“I feel like I learned how to see my kid differently… not just the behaviors, but what might be 

behind them” (Fiona, Group one). This reframing of their child’s behavior suggested a shift from 

reactive to reflective parenting, which was something taught in the parent training program and 

highlights potential personal growth from pre- to post-intervention.  

Caregivers also spoke candidly about the emotional labor involved in parenting a child 

with suspected autism and behavioral needs, noting how recognition and support within the 

program helped alleviate feelings of isolation. One caregiver reflected, “This is the hardest thing 

I've ever done. So having that support and just the acknowledgment of how layered and complex 

some of this can be was really like a breath of pressure. That I can do this. So, yeah, I really 

appreciated that as well" (Jamie, Group 3). 

Additionally, caregivers shared insights that reflected a change in how they responded to 

behavioral challenges. Rather than reacting instinctively, they began to implement intentional 

93 

 
 
 
 
strategies learned in the program, such as planned ignoring and proactive antecedent-based 

strategies. One caregiver described this shift by saying, “So, having the planned reaction I think 

was helpful because those are not things that I necessarily had thought of” (Campbell, Group 3). 

Theme 4: Community and Validation. The program not only taught parenting strategies 

but also created a space where caregivers could connect and feel heard. One caregiver shared, 

“The opportunity to learn or hear the experiences of other parents is just, like, priceless” (Fiona, 

Group one). Another noted, “Just hearing other people say the same thing, like, ‘Oh my gosh, I 

felt that too!’ it made me feel like I wasn’t alone” (Ellis, Group 2). 

Several caregivers valued both peer support and direct feedback from the interventionist. 

One caregiver highlighted, “Yeah. I think it was really helpful to bounce ideas off of other 

parents in the parent session. And then separately from that, having multiple opportunities for 

feedback from you was helpful” (Brock, Group 2). 

A few caregivers mentioned challenges with group size and recommended that future 

iterations of the project include more caregivers to create more fruitful conversation. For 

example, one caregiver noted, “Unfortunately, there was only one other family at one of the in-

person meetings. It made it a little bit challenging to talk about our circumstances. I still found 

value in the meeting but it would have been helpful if another family or two were able to 

participate.” (Lexis, Group one). Actually,  

Theme 5: Strengths and Weaknesses of the Program Structure. Participants identified 

several strengths in the structure of the intervention. The brief and accessible format was widely 

recognized. One caregiver shared, “I liked that it was short and clear. You didn’t feel like you 

had to have a PhD to understand it, but it didn’t talk down to you either” (Charlotte, Group one). 

The practical and applicable strategies were also viewed as a major strength. A caregiver stated 

94 

 
 
 
 
that, “It was very helpful to talk about practical strategies that we could implement immediately 

(e.g., first – then, concise directions)” (Sarah, Group 2), highlighting the value of concrete 

strategies. Another caregiver explained that they appreciate the personalized and strength-based 

approach using the COMPASS profile, when they noted, “The Behavior Intervention Plan 

focused on a specific concern that we identified. It included multiple suggestions to address 

inappropriate behavior. I also appreciated the time dedicated to talking about my child’s 

strengths.” (Campbell, Group 3).  

Additionally, the structure helped caregivers engage without adding extra burden to their 

schedules, and materials were described as empowering rather than overwhelming. They noted 

that it was accessible because it wasn’t long. Those who participated in the in-person sessions 

(groups one and two) noted that they appreciated having time to meet face-to-face, which helped 

deepen engagement.   

At the same time, participants also noted constructive feedback about areas for 

improvement. Several caregivers expressed wanting more consistent communication from the 

interventionist. One caregiver asked, “Do you think a weekly email could happen... especially 

because there were weeks where we didn't meet?” (Brock, Group 2). Others noted a desire for 

more autism-related resources. Even though the program explicitly noted that it did not cover 

diagnosis education or autism-specific education to avoid misinformation, some caregivers 

expressed interest in supplemental readings. One caregiver said, “Maybe some recommendations 

for, like, outside reading… that summarize or condense the different varieties of autism or how it 

presents itself” (Group 3 caregiver), suggesting that they would like resources they could read on 

their own time.  

95 

 
 
 
 
DISCUSSION 

Purpose and Significance of the Study 

This project evaluated the initial promise of The Collaborative Model for Promoting 

Competence and Success for Students with Autism (COMPASS) for HOPE (C-HOPE; 

Kuravackel et al., 2017) with caregivers of children who were waiting for an evaluation for 

autism. The study sought to determine whether participating in the program would reduce 

caregiver stress, increase caregiver efficacy and satisfaction, increase parent knowledge about 

behavioral principles, and reduce child behavior problems. Seven caregivers, including six 

mothers and one father of children on waiting lists for an evaluation for autism who had 

behavioral concerns completed the project.  

Supporting caregivers of children who are waiting for an evaluation for autism represents 

an important and understudied area of research. Currently, there are limited to no services 

provided for this group (Roberts et al., 2016). Consequently, caregivers are left to find ways to 

manage stress, increase efficacy, learn about behavior management, and support their child’s 

development.  

Grounded in and guided by the ABC-X Model of Stress and Coping, Transactional 

Model of Stress and Coping, and Social Learning Theory, the aim of this study was to address 

keys gaps in the field by supporting these caregivers. The study focused on supporting caregiver 

outcomes, aiming to reduce caregiver stress and increase self-efficacy and knowledge about 

behavioral principles. Participation in C-HOPE provided caregivers an opportunity to identify 

target behaviors unique to their needs. Together, the interventionist and caregiver developed an 

individualized BIP based on the child’s individual strengths and weaknesses.  

96 

 
 
 
 
 
 
The results of this study provide preliminary support for the potential efficacy and 

acceptability of the C-HOPE parent training program for caregivers of children awaiting an 

evaluation for autism. Statistically significant changes were observed across several outcome 

variables, including reductions in caregiver stress, increased caregiver satisfaction, increased 

knowledge about behavioral principles, and decreased child problem behavior intensity. No 

significant effects were observed for caregiver self-efficacy, but there was an increase in efficacy 

on average, with a positive effect.  

The acceptability ratings, combined with qualitative feedback on the intervention's 

structure, support, and relevance, suggest that caregiver participants found the program both 

supportive and validating. Though more research is needed to confirm the results, these findings 

suggest that brief, targeted, and individualized parent training interventions like C-HOPE may 

offer an important bridge to services during the waiting period for autism evaluation.   

Caregiver Outcomes Following C-HOPE 

Caregiver Stress 

Hypothesis one was confirmed; caregivers reported reduced stress levels post-

intervention. The results indicated a statistically significant reduction in caregiver stress among 

caregivers participating in the C-HOPE parent training program. Specifically, caregivers’ total 

stress scores on the PSI-4 SF significantly decreased from pre- to post-intervention, with a large 

effect size. These findings suggest that brief, targeted behavioral parent training may be 

efficacious in supporting the emotional well-being of caregivers during the often-prolonged 

period preceding an autism diagnosis. 

When examining these results in the context of prior C-HOPE studies, important patterns 

regarding effect sizes, interpreted using Cohen’s d, emerge. In the current study, large effects on 

97 

 
 
 
 
parent stress were found, whereas Kuravackel et al. (2017) reported a small effect size on this 

construct and Rogers (2018) reported a medium effect size for stress. Baseline stress levels were 

higher among participants in the current study than among participants in the original C-HOPE 

study (Kuravackel et al., 2017). There are many possible reasons for the difference in effect 

sizes. One explanation might be where the participants were recruited from. The participants in 

Kuravackel et al. (2017) and Rogers’ (2018) studies were from rural locations, whereas 

participants in the current study were recruited from both rural and metropolitan regions. 

Differences in life stressors and service accessibility between these populations may have 

influenced caregiver stress levels. In particular, participants from the current study reported that 

caregiver stress was not only a reaction to child behavior, but due to systemic barriers, 

uncertainty of the waiting list, and self-neglect of one’s own well-being as a caregiver. Another 

possible explanation for this difference is that caregivers in the previous study had children 

diagnosed with autism, whereas children of the caregivers in the current study were not yet 

evaluated or diagnosed. For example, those in the previous research studies may have already 

accessed services or interventions aimed at stress reduction, potentially limiting the impact and 

strength of C-HOPE. However, these interpretations are just a hypothesis and remain 

speculative.  

 Similarly, post-intervention scores remained higher in the current sample than those in 

the original study. However, the current findings are more closely aligned with the results from 

Rogers et al. (2018), where caregiver stress pre-intervention averaged M = 122.60 (SD = 25.73) 

and decreased to M = 109.50 (SD = 26.47) at post-intervention, with a small effect. These 

comparisons are important to contextualize the degree of change observed. To explain, 

caregivers in the present study appear to have begun the intervention with more elevated stress, 

98 

 
 
 
 
suggesting that there was greater need for support and potentially more room for meaningful 

reductions. Thus, this may be why there was large reduction in stress pre to post intervention in 

the current study. Moreover, the reduction in stress levels across the current study and 

Kuravackel et al. (2017; sample included caregivers of diagnosed autistic children) and Rogers 

(2018; sample included caregivers of diagnosed autistic children) suggest that C-HOPE can 

reduce caregiver stress with both caregivers of children diagnosed with ASD and not.  

Though caregivers reported significantly reduced stress and with large effects, on 

average, after completing the intervention, variability was observed in the degree of stress 

reduction at the individual level. One participant’s stress level remained unchanged and in the 

clinically severe range, and two others showed no change from pre- to post-intervention. These 

findings suggest that while C-HOPE may be broadly efficacious, some families may require 

more intensive, tailored support to see substantial change. They might also require higher 

dosage, including more sessions and time with the interventionist and other caregivers. 

Individual differences such as caregiver social support or child behavioral intensity may 

moderate the strength of intervention effects and should be explored in future studies.  

High levels of stress among caregivers of children with suspected autism are well-

documented in the literature (DesChamps et al., 2020). Caregivers often report elevated stress 

levels related to behavior management, communication difficulties, uncertainty regarding the 

diagnostic process, and systemic barriers to accessing care (Mulligan et al., 2012; Zuckerman et 

al., 2015). Research has shown that these stress levels are often exacerbated during the 

diagnostic waiting period, a time marked by lack of clarity and prolonged service delays 

(DesChamps et al., 2020). The current findings align with previous research that has 

demonstrated the efficacy of parent-mediated interventions in reducing caregiver stress in the 

99 

 
 
 
 
context of autism (e.g., Brookman-Frazee et al., 2012; Ingersoll & Wainer, 2013). Importantly, 

the C-HOPE parent training program was adapted to specifically address the needs of families 

awaiting an evaluation for autism, a period that has received less empirical attention. Even 

without a confirmed diagnosis or access to formal services, brief parent training programs and 

subsequent individualized behavioral intervention plans may reduce stress levels in a meaningful 

and quantifiable way.  

Across all four focus groups, caregivers described experiencing high levels of stress and 

emotional overload prior to the intervention. Themes such as Caregiver Stress and Emotional 

Overload and Personal Growth and Parenting Journey offered direct insight into caregivers’ 

emotional states and their perceived shifts across the intervention. One caregiver expressed that 

learning to “stay on top of my stress” was a turning point in their experience, suggesting a shift 

toward increased emotional self-awareness and strategies for stress regulation. There are several 

other possible mechanisms for why caregiver stress may have reduced from pre- to post-

intervention. One possibility connected to reported increases in parent knowledge about 

behavioral principles (discussed in research question three), is that caregivers gained a deeper 

understanding for their child’s behaviors and learned tools to support them. This increase in 

knowledge may have encouraged caregivers to manage their child’s behavior more effectively 

and use evidence-based strategies. Based on the ABC-X model, caregivers may have increased 

their resources (i.e., strategies) which may have resulted in a reduction in their perception of the 

stressor (i.e., child problem behavior). Significant reductions were found on the child behavior 

intensity measure using the ECBI. These reductions align with the literature that improved child 

behavioral outcomes can contribute to lower caregiver stress (discussed in research question 

four; Lecavalier et al., 2006; Vaughn et al., 2013). Third, caregiver support and feeling validated 

100 

 
 
 
 
are known buffers again stress (O’Dea & Marcelo, 2023). Through the tenants of social learning 

theory, caregivers received practice and feedback on the strategies taught.  It is possible that the 

caregiver support provided in sessions three and five, as well as the caregiver coaching 

component provided in five, might have improved caregiver stress. In sum, the foundation 

underpinning C-HOPE, which emphasizes caregiver education, skill-building, stress reduction, 

emotional validation, and peer connection, may be particularly well-suited to address the 

complex origins of caregiver stress.  

Caregiver Satisfaction and Efficacy 

Hypothesis two was partially confirmed; caregivers reported increased satisfaction levels 

post-intervention, however, efficacy levels did not significantly change. Although, over half of 

the participants reported individual-level gains in efficacy from pre- to post-intervention and 

there was a moderate effect size found. With a larger sample, statistical significance might be 

achieved. These findings suggest that brief, targeted parent training may positively influence 

caregivers’ emotional experiences of parenting (satisfaction) and may also support initial 

movement toward increased confidence in parenting abilities (efficacy). 

Satisfaction. It is important to examine changes in parenting satisfaction following 

participation in parent training, as satisfaction often reflects caregivers’ sense of fulfillment and 

enjoyment in their parenting role. In the context of raising a child with suspected autism and 

behavioral concerns, satisfaction can be reduced by variables such as daily stressors, uncertainty 

about diagnosis, and strained parent–child interactions (Solia et al., 2024; Zuckerman et al., 

2015). 

The C-HOPE parent training intervention’s emphasis on child strengths, individualized 

behavioral goals, and relational support may have helped restore the emotional gratification in 

101 

 
 
 
 
parenting. Through developing the COMPASS Profile, families built the behavior intervention 

plan (BIP) based on their child’s strengths. Consistent with the ABC-X Model, leveraging a 

family’s individual resources (i.e., strengths) likely enhanced the tailoring of strategies to better 

meet their needs. Qualitative feedback supports this interpretation. Caregivers frequently 

expressed that they felt validated and valued during the intervention process. For example, one 

caregiver shared that the interventionist in the program “didn’t talk down to you” but offered 

tools in a way that was empowering. Another caregiver reflected that being in a group with other 

caregivers helped reduce isolation and made them feel like “they weren’t alone,” a known 

contributor to higher parenting satisfaction (Khanna et al., 2011; Lui et al., 2023). These findings 

are aligned with prior research showing that parent training programs rooted in positive 

parenting, validation, and goal alignment tend to result in increased satisfaction post-intervention 

(McIntyre, 2008; Totsika et al., 2016). Considering the Transactional Model of Stress and 

Coping, it could be suggested that caregivers evaluated their resources and coping strategies (i.e., 

secondary appraisal) more positively and felt they could manage their stress better.  

Further, research on parent training highlights that caregivers report improvements in 

caregiving satisfaction following both in-person and telehealth parent training interventions (Dai 

et al., 2021; Pickard et al., 2016). Caregivers report both satisfaction with their parenting 

strategies post-intervention and their outlook on caregiving (Ingersoll & Berger, 2015). 

Considering the current study, caregivers noted high levels of satisfaction with parenting, while 

also demonstrating qualitative insight into feeling more satisfied with the tools they had. For 

example, a caregiver reported that they felt they knew how to handle their child’s behavior and 

that made them feel more fulfilled with being their parent.  

102 

 
 
 
 
Efficacy. Although caregiver efficacy increased on average following the program, the 

change did not reach statistical significance. While not statistically significant in this study, the 

data trended toward increased efficacy, with a medium effect size, which suggests that there may 

be a moderate relationship between participation in the intervention and changes in caregiver 

efficacy. It is possible that the brief duration of the intervention was not enough to increase 

efficacy, or that the small sample precluded detection of a significant difference between pre- 

and post-intervention efficacy scores. Additional time and practice applying strategies in real-life 

contexts may be needed before caregivers report a stronger sense of competence. Future sessions 

might add additional sessions to increase efficacy. It is also possible that caregivers’ unanswered 

questions about how to support other areas impacted in autism, such as social communication, 

social interaction, and restricted and repetitive behaviors, also contributed to relatively smaller 

gains in efficacy. Additionally, it is possible that the sample size in the current stay was too small 

to detect significance.   

Importantly, caregiver individual reports provided evidence of shifts in caregivers’ 

mindset on behavioral strategies that related to their sense of efficacy. Caregivers described 

learning to approach behavior more intentionally and noted increased understanding of what to 

do when challenging behaviors arose. One caregiver shared, “Having the planned reaction… was 

helpful because those are not things I necessarily had thought of.” Given the medium effect size 

found, it can be suggested that efficacy still increased because caregivers were taught how to 

respond to their child’s behavior more effectively. Such comments suggest that while caregivers 

may not yet fully endorse confidence in their skills on standardized measures, they are beginning 

to adopt new behavioral strategies consistent with higher efficacy. These data also bolster the 

103 

 
 
 
 
large effect that was found with the parent knowledge measure (see Caregiver Knowledge 

section).  

These findings differ from those of similar studies, where other studies have found that 

efficacy increases after participation in parent training (Deb et al., 2020). Notably, these studies 

also had larger sample sizes (e.g., 89 participants), which increases statistical power and reduces 

random error. To date, no comparable studies have evaluated changes in caregiver efficacy 

following a parent training program delivered to caregivers of children waiting for an evaluation 

for autism. However, within the broader neurodevelopmental disabilities literature, participation 

in parent training consistently results in increases in caregiver self-efficacy (Hohlfeld et al., 

2018). In the review conducted by Hohlfeld et al. (2018), the authors highlighted that self-

efficacy increased when providing parent training interventions for caregivers of younger 

children (<5 years) and that manualized or licensed parent training interventions increase 

efficacy levels. Several factors from this review may help explain why the current study did not 

find statistically significant results. First, the small sample size likely limited the ability to detect 

effects, even if present. Second, caregivers awaiting evaluation often face heightened uncertainty 

and stress, which may make it more difficult for parent training to shift efficacy in a short time 

frame (Zuckerman et al., 2015). Third, the sample in this study included children above the age 

of 5 years. It is possible that caregiver efficacy is more stabilized in alter childhood and thus less 

amenable to change.  

The variation in findings between satisfaction and efficacy are meaningful. Satisfaction is 

more emotional and relational, and may be immediately impacted by social support, validation, 

and a sense of being heard (Le & Impett, 2019). Efficacy, in contrast, is a belief, and may require 

more time, practice, and evidence of success to significantly shift (Bandura, 1978; Feeney & 

104 

 
 
 
 
Collins, 2015). Thus, it is possible that the immediate gains in satisfaction reflect the program’s 

success in improving the caregiver’s emotional experience of parenting and connection to others, 

while efficacy may follow over time as behavioral strategies are reinforced and generalized 

across settings. This pattern has been suggested in other parenting literature, where increased 

satisfaction can serve as a motivational precursor to building efficacy over time (Glatz & 

Bauchanan, 2015).  

In the current study, subscales (i.e., efficacy and satisfaction) were used, whereas prior 

studies of C-HOPE used the total competence score; however, broad comparisons can still be 

made. The effect sizes, interpreted using Cohen’s d,  in the current study reflect a medium effect 

for both self-efficacy and satisfaction, whereas previous C-HOPE research reported small to 

medium effect sizes for competence. Kuravackel et al. (2017) found a small effect on caregiver 

competence with a sample of caregivers with autistic children. Dahiya et al. (2021) found an 

overall medium effect with caregiver competence. Dahiya et al. (2021) also looked at 

comparisons among the participants from urban settings versus rural settings. They found a 

medium effect size when comparing participants from urban setting to participants from urban 

settings and a medium effect size when comparing participants from rural settings to participants 

from rural settings on pre/post BPS competence total score. Unlike earlier studies that recruited 

from primarily rural settings (Kuravackel et al., 2017) or made urban-rural comparisons (Dahiya 

et al., 2021), the current study recruited from both metropolitan and rural regions. Caregiver 

access to services and perceived gains may have been influenced by broader sampling, which 

could explain the variation in effect sizes when comparing this study to previous research on C-

HOPE.  

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Rogers (2018) did not report effect sizes for caregiver competence; however, mean 

differences suggested that caregivers had lower competence at post-intervention. The trends in 

these means and standard deviations were dissimilar to the current study, which found caregivers 

reported higher levels of efficacy and satisfaction at post-intervention. There were procedural 

differences across the two studies. The adapted C-HOPE intervention in this study placed a 

greater emphasis on flexible delivery methods (e.g., virtual and in-person options), which may 

have enhanced engagement and efficacy with the intervention material. Rogers (2018) conducted 

their study through an online asynchronous modality. It is possible caregivers reported lower 

scores on these constructs because they did not have face-to-face contact with the 

interventionists and other caregivers (Todd & Niec, 2025). Additionally, Rogers (2018) study 

was conducted with caregivers of autistic children. As noted previously, it is possible that these 

caregivers had processed their role as a caregiver of a child with a neurodevelopmental disorder 

and thus did not report higher self-efficacy or satisfaction (e.g., Keen et al., 2010). It is possible 

the participants in the current study may have demonstrated gains in efficacy and satisfaction 

because they learned new information about their child and were able to apply this knowledge to 

their parenting practices.  

Caregiver Knowledge  

Hypothesis three was confirmed; caregivers reported increased knowledge about 

behavioral management post-intervention. The effect sizes, interpreted using Cohen’s d, also 

parallel those found in Dahiya et al. (2021). These findings suggest that brief, targeted behavioral 

parent training may result in gains in caregivers’ knowledge about behavioral concepts that can 

be used when providing support for their children who demonstrate risk for autism and 

behavioral challenges. 

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Furthermore, all seven caregivers showed individual-level gains in knowledge from pre- 

to post-intervention. This finding suggests that caregivers were able to retain and apply the 

information shared by the interventionist. Through Social Learning Theory, it can be 

hypothesized that caregivers observed behavioral strategies from the interventionists and peers, 

practiced skills with feedback, and received positive reinforcement, which may have increased 

their knowledge. The increase in parent knowledge aligns with previous studies that have 

demonstrated the efficacy of psychoeducation and behavioral training in increasing knowledge 

among caregivers of children with autism and their understanding of behavioral strategies 

(Rodgers et al., 2016; Wainer & Ingersoll, 2015). More broadly, these results echo the literature 

on parent-mediated interventions, such as the Positive Parenting Program (Triple P; Sanders et 

al., 2000) and Parent-Child Interaction Therapy (PCIT; Eyberg et al., 1995), both of which have 

demonstrated improvements in parent knowledge and behavioral strategy use. Programs such as 

the Triple P and PCIT direct clinicians to use a similar approach to teaching their material. For 

example, clinicians teach, show the caregivers how to use target skills, and then allow the 

caregivers opportunities to practice the strategies with feedback. In addition to the process for 

teaching the material, Triple P and PCIT also cover similar content around behavioral 

intervention strategies (e.g., planned ignoring).  

As Kaminski et al. (2008) notes, measuring parent knowledge is a well-documented and 

valuable approach to evaluating parent training intervention outcomes. This is because 

researchers can measure what specific items caregivers learned after participating in the 

program. Outcomes on parent knowledge may be meaningful considering evidence showing that 

caregivers of children with autism often feel underprepared and ill-equipped to address their 

child’s behaviors prior to diagnosis or the initiation of formal services (Gentles et al., 2020; 

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Smith-Young et al., 2020). Moreover, limited knowledge about behavioral principles may 

contribute to ineffective parenting strategies (e.g., reinforcing “problem behavior”) and increased 

stress or frustration (Zuckerman et al., 2015; Lecavalier et al., 2006). Thus, improving parent 

knowledge about behavior management before receiving a possible autism diagnosis for their 

child may serve as a protective factor through enhancing caregivers' understanding of behavior, 

building confidence, and promoting more effective and consistent responses to behavioral 

challenges. Participation in the C-HOPE parent training program may help bridge a critical gap 

in caregiver readiness and confidence by equipping caregivers with these foundational 

behavioral education during the evaluation waiting period.  

 Caregivers discussed learning to interpret their child’s behavior child’s behavior. One 

caregiver stated, “I feel like I learned how to see my kid differently... not just the behaviors, but 

what might be behind them.” This insight demonstrates a deeper understanding of the functions 

of behavior. Caregivers also described how practical tools and strategies helped solidify their 

understanding. For example, one parent shared, “It was very helpful to talk about practical 

strategies that we could implement immediately,” pointing to the value of bridging conceptual 

knowledge with real-life techniques. Kunze (2021) found similar feedback from their caregiver 

participants in their intervention on reducing RRBIs in autistic children when participants noted 

they were appreciative to receive strategies and apply them with coaching. Again, the current 

findings provide preliminary evidence that some of the knowledge may have been applied into 

aspects of caregivers’ daily lives.  

Child Behavior  

Hypothesis four was supported; caregivers reported significant reductions in child 

behavior problems post-intervention. Various behaviors were targeted in the intervention, 

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ranging from school refusal, non-compliance, and difficulties with transitions. Caregivers were 

taught stress reduction techniques such as mindfulness and identifying social outlets. After stress 

techniques were taught, interventions were collaboratively developed by the interventionists and 

the caregiver, using the child’s individual environmental and personal strengths and challenges. 

For example, one child had difficulty with transitions (personal weakness), so the child was 

given a Mario Party-themed first/then schedule (i.e., they loved Mario Party and their caregiver 

reported they were both creative and skilled in video games - personal strength). The caregiver 

then provided the child a token every time they transitioned throughout their day. After a certain 

number of tokens, the child received a reward. See the Appendix J for the full case example.  

Results revealed a statistically significant decrease in child behavior intensity as 

measured by the ECBI, with a large effect size. At the individual level, the majority of 

participants reported reductions in child behavior concerns that shifted from the clinically 

significant range to within normal limits. These findings suggest that the intervention may 

positively impact child outcomes even during the pre-evaluation period, when access to 

interventions services is typically limited.  

Two participants did not report clinically significant reductions in child behavior 

concerns. These two caregivers were a part of the third group and were recruited from a different 

state. It is possible that there were external factors, such as geographic location and resources, 

that influenced the intensity of the child’s behaviors. These factors were not able to be controlled 

for. In addition, the target child behavior for both of these caregivers was non-compliance. 

Caregivers may have been under a higher level of stress due to the noncompliant behavior when 

compared to other caregivers whose target behaviors were less frequent. For example, one 

caregiver’s child’s target behavior was school refusal, which occurs once per day for five days a 

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week. Non-compliant behaviors can occur more frequently and therefore the caregivers might 

have rated their intensity as higher. Second, one of the caregivers was married but noted that they 

were the primary caregiver. When compared to other caregivers, this caregiver may feel the 

behavior was more intense because they were primarily supporting their child’s behavior. Lastly, 

fidelity of intervention may have influenced caregivers to report no behavioral change. Caregiver 

intervention fidelity has been shown to decrease child challenging behavior (Strauss et al., 2012). 

The two caregivers were each provided token economy reinforcement systems and provided 

instruction on differential attention. These interventions have strong evidence when implemented 

correctly (Doll et al., 2013; Kern & Kokina, 2008, pp. 414). It is possible that the caregivers 

implemented the interventions with low levels of fidelity, which resulted in no changes to 

behavior intensity. However, this is an assumption. Caregiver fidelity should be collected in 

future iterations of this study to control for these changes.  

Beyond statistical significance, the reduction in ECBI intensity scores suggest 

meaningful changes may have occurred in the frequency of children’s disruptive behavior. For 

most participants, scores fell below the clinical threshold (T-score £ 60), suggesting that the 

intervention reduced behaviors, bringing them to non-clinical levels. Given that elevated 

behavior problems are one of the most common reasons caregivers seek evaluation and are 

predictive of long-term service needs (Jonston & Burke, 2020), this finding provides promise for 

reducing child behavior by participating in C-HOPE. 

Effect sizes regarding change in child behavioral concerns, interpreted using Cohen’s d, 

were variable across this dissertation study and the other three studies of C-HOPE. Kurvackel et 

al. (2017) reported a small effect size, Rogers (2018) reported a large effect, and Dahiya et al. 

(2021) reported a small effect. The effect size reported in the current study was large. High 

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behavioral intensity reported by caregivers at baseline may partially explain the large effect in 

behavioral change. Findings suggests that C-HOPE may be particularly beneficial for families 

experiencing high levels of behavior challenges. For example, in the original C-HOPE pilot 

study conducted by Kuravackel et al. (2017), caregivers reported lower behavior intensity than 

caregivers in the current sample. Caregivers from Rogers et al. (2018) reported an average pre-

intervention behavior intensity score of M = 146.40 (SD = 35.36), which decreased to M = 

123.10 (SD = 28.35) following the intervention. Despite these pre-post differences, the consistent 

pattern of reductions in child behavior intensity across the current study, Kuravackel et al. 

(2017), and Rogers et al. (2018) reinforces the potential that participating in C-HOPE can reduce 

behavioral challenges in children regardless of diagnostic status, whether formally diagnosed 

with ASD or identified as at-risk. Moreover, these findings suggest that C-HOPE may yield 

similarly meaningful post-intervention outcomes across varying clinical profiles. 

The reductions in behavioral concerns reported by caregivers following C-HOPE 

participation align with existing literature supporting parent-mediated behavioral interventions 

for children with or at risk for autism (Ratliff-Black & Therrien, 2020). In general, prior 

systematic reviews and metanalysis report positive effects on autistic children’s behavior, 

communication, social skills, and adaptive functioning following participation in parent training 

interventions (Cheng et al., 2023). Regarding behavior, teaching caregivers to implement 

evidence-based strategies, such as planned ignoring, differential reinforcement, and antecedent-

based modifications, has been shown to improve adaptive child behavior (Crowell et al., 2019). 

Additionally, as caregivers reshape their behavioral responses, improvement in child behavior 

often follows suit (Karst & Van Hecke, 2012). Thus, the gains in desired child behavior may 

reflect changes not only in the children themselves but also in the parents’ capacity to manage 

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and respond to those behaviors effectively. In addition, prior parent training research has shown 

that high-stress environments often reinforce negative child behaviors through unintentional 

reinforcement patterns (Jones et al., 2021). As caregivers in this study experienced decreased 

stress and increased satisfaction (RQ1 & RQ2), it is possible that caregiver strategies became 

less reactive and more proactive, breaking cycles that reinforce and maintain externalizing 

behaviors. Interpreting this through the lens of the ABC-X Model, it can also be argued that as 

child behaviors were proactively managed, caregivers perceived the behavior to be less 

challenging to manage, thereby reducing caregiver stress.   

It should be noted that this study included a sample of caregivers of children awaiting an 

autism evaluation, a group that is often underserved and excluded from intervention until a 

formal diagnosis is confirmed (Zuckerman et al., 2015). These findings therefore support the 

notion that early intervention may still be beneficial in reducing child behavior concerns before 

formal assessment. 

Parent training research broadly demonstrates that individualized interventions tailored to 

unique child behaviors also reduce problem behaviors (Dyson et al., 2019). In the current study, 

caregivers highlighted observing noticeable differences in their child’s response to behavior 

strategies learned in the program. For example, one caregiver described how planned reactions 

helped reduce behavioral escalation. Additionally, the Support Needs and Access to Resources 

themes highlighted how the intervention filled a critical gap by offering hands-on, practical 

strategies when no other services were available. Research demonstrates that receiving concrete 

parent training tools supports caregiver’s use of parenting strategies (Dyson et al., 2019). In the 

present study, caregivers emphasized the value of having concrete tools they could use in 

everyday settings, rather than just general advice they could find searching the internet. This type 

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of applied knowledge appears to have directly influenced how children responded at home. The 

theme Personal Growth and Parenting Journey also revealed how caregivers reframed their 

understanding of behavior, seeing it not as “bad” or “intentional,” but as communication. 

According to the Transactional Model of Stress and Coping, this shift reflects a more adaptive 

primary appraisal of behavior, where caregivers reinterpret behavior as communication rather 

than intentional misbehavior. This reappraisal likely reduced caregivers’ emotional reactivity and 

helped them identify more effective caregiving strategies. This shift in perspective is consistent 

with behavior analytic principles and likely improved the potential efficacy of caregiver 

implementation by increasing empathy and consistency. Additionally, the program’s 

individualized BIPs, developed using the COMPASS framework, likely helped caregivers 

directly address specific problem behaviors with tailored strategies. Crowell et al. (2019) note 

that tailoring evidence-based strategies can increase caregivers’ use of the strategies. Caregivers 

expressed appreciation for these plans in qualitative interviews, noting that they provided a 

“guide” for addressing behavior proactively. They also shared how they appreciated that the 

strategies were informed by their child’s unique environmental and personal strengths and 

challenges.  

Implementation Outcomes 

Acceptability, Appropriateness, and Feasibility  

Acceptability of Intervention (AIM). Hypothesis five was confirmed – caregivers 

reported high levels of acceptability. In this study, the acceptability of the C-HOPE intervention 

was assessed through both quantitative (Acceptability of Intervention Measure; AIM) and 

qualitative (focus group) data. The high acceptability ratings across all items of the AIM suggest 

that caregivers consistently endorsed the program as acceptable. In implementation science, such 

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ratings are considered a necessary precondition for broader adoption and scalability of an 

intervention (Aarons et al., 2019). High acceptability is especially notable given the context of 

the intervention, often during a time of heightened stress, uncertainty, and service delays. High 

acceptability is one of the key indicators of implementation readiness and is often associated 

with improved engagement, fidelity, and outcomes (Proctor et al., 2011; Weiner et al., 2017; 

Weiner et al., 2020). This study of the adapted C-HOPE intervention is a first step to 

understanding whether this intervention is potentially acceptable, and findings offer promise that 

it may be for parents who choose to participate.   

Importantly, acceptability ratings were high even though many families participated in 

the program at the end of an 8-hour workday. It is possible that the program’s brief, flexible, and 

multi-modal delivery format (e.g., virtual sessions, individualized coaching) may have 

contributed to its success in reducing participation burden. These findings are further supported 

by the qualitative data, which provided additional insights into the perceived strengths and 

weaknesses of the program and its relevance to caregivers’ lived experiences. Ellis from group 

two highlighted that “I really needed something like this. Not just something telling me to 

breathe but showing me what I can do with my child.” Her reflection provided in the focus group 

alluded to wanting a parent training program that wasn’t just focused on her child, but also on 

her own unique stress. As noted, most parent training programs are focused on child behavior 

and not on the caregiver (Gubbels et al., 2019). One caregiver noted that they found value in 

receiving a BIP that they could implement right away and that they had the tools and knowledge 

do to it themselves. This caregiver said, “It was one pretty package. You’re like here you go.” 

Again, highlighting that not only was stress reduction techniques helpful for caregiver, but the 

BIP on managing their child’s behavior was also beneficial. Regarding weaknesses, Ellis noted 

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that “I would have loved that there were more parents in the group, but, you know…” This was 

both a weakness for the caregiver and a noted area for improvement in future research.  

Intervention Appropriateness (IAM). Quantitative results indicate that caregivers who 

agreed to participate and remained enrolled throughout the entire intervention found the 

intervention to be highly appropriate, suggesting that these caregivers found C-HOPE to be 

adequate for their current needs. Qualitative data bolster these findings and demonstrate areas for 

improvement. Charlotte from group one noted, “Having the planned reaction I think was helpful 

because those are not things that I necessarily had thought of.” This quote suggests that this one 

specific strategy was appropriate for their caregiving needs. Regarding areas for improvement, 

caregivers expressed wanting more information on autism-specific education and resources on 

autism. Given that this dissertation was shared as an intervention for caregivers waiting for an 

evaluation for autism for their child, it is likely that caregivers assumed they would learn more 

about autism. This was not an aim of the study, but caregivers noted that this was one piece that 

was missing but of interest. For example, Campbell from group three said, “Maybe some 

recommendations for, like, outside reading… that summarize or condense the different varieties 

of autism or how it presents itself,” highlighting that they would be happy to learn on their own 

time if the information was provided. Although the resources and direct education on autism 

were intentionally removed from the adapted C-HOPE intervention due to not wanting to 

confuse caregivers about autism if their child ended up not meeting criteria for an autism 

diagnosis, there may be value in reintegrating this content back into future iterations of the 

intervention.  

Feasibility of Interventions (FIM). Quantitative results indicate that caregivers who 

agreed to participate and remained enrolled throughout the entire intervention found the 

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intervention to be highly feasible, suggesting that these caregivers found C-HOPE to be practical 

and the strategies were likely to be used in real life. In addition to the measure, caregivers 

provided direct insight into their experience with the intervention during intervention sessions. 

As an example, during session six, caregivers met with the interventionist one-on-one to work 

through successes and challenges they were having with the BIP. For instance, Jamie from group 

three shared concerns that their child would regress on their target behavior (i.e., school refusal) 

during breaks from school. The clinician and this caregiver discussed ways to generalize the 

strategies to make them more feasible during holiday breaks. Caregivers across all three groups 

generally expressed that the interventions were feasible and that they were implementing them. 

Additionally, caregivers shared a series of recommendations. 

Though these findings are encouraging, it is difficult to draw conclusions about the 

acceptability and feasibility of the intervention, and intervention appropriateness given the small 

sample size and attrition. For example, it is possible that the caregivers who found C-HOPE to be 

acceptable remained for the duration of the intervention while those who did not withdrew. 

Given this possibility, it would be advantageous to repeat this study with a larger sample size to 

examine whether similar patterns of acceptability and feasibility are found, and to assess the 

intervention’s appropriateness across various caregivers. Additionally, it would be beneficial to 

gather data on why caregivers chose to discontinue the intervention. The three participants who 

enrolled but later withdrew did so after either the first or second session. This pattern suggests 

that caregivers may have disengaged before attending the first in-person session, potentially 

indicating a preference for, or a greater perceived value in, the asynchronous components of the 

program. Alternatively, it is possible that the early sessions did not sufficiently engage them, and 

that other formats, such as the in-person or synchronous virtual sessions, might have better 

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supported their engagement. This would be beneficial data to collect to inform future studies of 

C-HOPE.  

Feedback Regarding Future Intervention Development  

Reminders. Caregivers expressed a desire for more frequent session reminders. While 

weekly reminders were sent, participants suggested that an extra reminder would have better 

supported their engagement.  

Accessing Materials. Across both groups, caregivers reported difficulty navigating the 

Dropbox folder used to distribute weekly session materials. Many expressed uncertainties about 

which resources to review each week and requested a more streamlined approach. Specifically, 

participants suggested having a clear syllabus or consolidated folder with all materials organized 

by session. Additionally, several caregivers requested summary handouts to accompany the 

video content, which were provided after the sessions. However, providing these resources 

earlier may have improved accessibility and engagement as caregivers could have followed 

along on paper while watching the parent training sessions. This feedback highlights an 

opportunity to enhance future iterations by offering a synthesized packet of PowerPoints and 

handouts at the outset of the intervention. 

Data Collection. Caregivers noted that they had difficulty integrating some of the 

procedures into their day-to-day routine. For example, one caregiver reported that the process of 

collecting data to identify the function of the behavior was challenging. They reported that it was 

difficult to integrate this data collection method into their daily routines, potentially impacting 

the consistency and reliability of the data. Data collection for caregivers included collecting 

frequency counts of the behavior, duration of the behavior, and antecedent-behavior-

consequence (ABC) data. To address the challenges caregivers faced with collecting data, future 

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research could explore alternative data collection methods. Future researchers might use more 

simplistic data collection methods that are more integrated into caregivers' daily routines. Digital 

tools or mobile applications could also be developed to make data collection more seamless and 

user-friendly. Additionally, training caregivers in data collection techniques and providing 

ongoing support throughout the process could help improve the accuracy and ease of data 

collection. This could be incorporated into a pre-recorded module that caregivers could watch as 

an additional resource outside of the six-session intervention. Pilot testing different data 

collection methods prior to the full study could also help identify and mitigate potential barriers 

to participation. 

Limitations  

This study had several limitations that affected the overall recruitment, participant 

engagement, and methodology.  

Recruitment and Sample Limitations  

Sample size. A primary limitation was the small sample size, which stemmed from 

difficulties in recruitment and the constraints of the study's timeline and available resources (e.g., 

interventionists’ availability). Due to the recruitment difficulties, the sample size was too small 

to provide adequate statistical power for Analysis of Variance (ANOVA), the statistical analysis 

originally proposed for the study. Instead, dependent samples t-test were conducted. The small 

sample size limits statistical power and generalizability. Small sample sizes increase the threat to 

external validity (Findley et al., 2021), resulting in less ability to draw inferences from a sample 

and compare them to a larger population. Although the observed effect sizes were large and 

robust to sensitivity analyses (i.e., Influential Case Analysis - Leave One Out Method), larger 

randomized controlled trials are needed to confirm these effects.  

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Homogenous Demographics and Cultural Diversity. This project was limited to a 

relatively homogenous group. To be specific, 86% of caregivers (n = 6) identified as female and 

14% of caregivers (n = 1) identified as male. Most caregiver participants (five; 71%) were 

White. Additionally, most caregivers had incomes over $100,000 and were educated, with higher 

education degrees. One of these limitations was also highlighted by a caregiver who expressed 

that they would like more participants in the group to be of color as cultural representation and 

cultural alignment meant a lot to her. It is important to note that these demographic variables do 

not represent a representative sample of caregivers in the United States, which again increase 

threats to external validity (Findley et al., 2021). Additionally, caregivers were well-educated. It 

is possible that they found value in research and thus were more motivated to continue through 

the length of the program.   

Child Age. Children ranged from 5 to 12 years (M = 8.30). However, prior research 

consistently highlights that caregivers of children under the age of five often seek evaluations for 

autism (Hyman et al., 2020). As a result, children in early childhood were not well-represented in 

this sample. This was likely influenced by the eligibility criteria for child age, which was 3 to 12 

years of age. Further, children under the age of five are often met with a more streamlined 

processes for getting an evaluation because the diagnosis is needed to access early intervention 

(Hyman et al., 2020). These younger children frequently wait less for evaluations and get 

diagnoses quicker (Hyman et al., 2020). For example, clinicians and medical professionals often 

provide developmental screeners at well-child visits, which lead to a briefer evaluation and 

diagnosis. Thus, it is likely that children under five were not on waiting lists for as long and thus, 

did not seek out the adapted C-HOPE parent training program. Consequently, only a small subset 

of those awaiting an evaluation for autism had the opportunity to participate in the study.  

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Attrition and Missing Participants. Attrition was another significant limitation, with 

groups one and two experiencing a 50% drop-out rate, which compromised the potential 

robustness of the findings as less data was collected. Group one faced additional complications 

when one caregiver was absent during session 6, intended for peer-to-peer coaching and 

consultation, likely limiting the potential efficacy of that session because the caregiver’s that 

attended it received less peer coaching as they would have had the potential to receive coaching 

from two other caregivers had the one caregiver joined. Group three did not have participants 

drop out. It is possible that no participants dropped out because the group was fully virtual, 

allowing for more accessibility. Alternatively, caregivers might have felt more buy-in to the 

parent training program because their request for it to be fully virtual was honored.  

Although many caregivers expressed initial interest in the study (N = 36), only 10 

ultimately enrolled, and 7 completed the full intervention. Difficulties in recruiting and retaining 

caregivers are common in caregiver-focused research, especially when working with families of 

young children who may not yet fully recognize their own support needs or the potential benefits 

of intervention participation (Chacko et al., 2016). Recruitment is often challenging even when 

families indicate interest, as expressed interest does not always translate to enrollment or 

sustained participation. For example, Chacko et al. (2016) found that many families drop out of 

the intervention before they begin. 

Each family who dropped out was asked why and responses were variable. Reasons for 

non-enrollment or dropout included high caregiver burden, conflicting family schedules, and 

competing life demands. Some caregivers also may not have been aware of what the intervention 

entailed or how it could benefit them, which may be relevant for caregivers of younger children 

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who are early in the diagnostic journey and may not much about parent training program or how 

to support their child’s behavioral development.  

Interventionists and Modality Differences Across Groups 

Another limitation surrounds differences in the interventionists running the groups and 

the modality of the sessions. The C-HOPE parent training groups were run by two different 

trained interventionists. The first two groups were run by one interventionist in the original 

format (see method; Table 5). For the third group, all sessions were delivered by a different 

interventionist in a fully virtual format due to geographic relocation of the PI and caregiver 

scheduling needs. There was a mix of in-person and virtual/self-directed sessions for groups one 

and two, while group three was entirely online but with the same synchronous versus self-

directed features.  

These variations in both interventionists and modality represent potential sources of 

variability in caregiver engagement and program experience. Differences in delivery format, 

rapport with the interventionist, and interactional style may have introduced uncontrolled 

variables that may have influenced outcomes on the BPS, PKQ, PSI-4 SF, ECBI and 

AIM/FIM/IAM measures. Although, fidelity was tracked each session by a researcher, who 

compared a fidelity checklist of required session topics to the content that interventionist actually 

covered. Fidelity was high across the three groups, suggesting that the different interventionists 

delivered the intervention with comparable quality.  

Measurement Limitations 

Several measurement limitations should be noted. First, behavior intensity was measured 

using a caregiver-report instrument (i.e., ECBI), which may be influenced by caregiver bias 

about their child’s behaviors. Future studies should include direct observational measures, such 

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as structured video-based behavioral observations, to validate caregiver reports. Research 

highlights that multi-mode data can increase reliability (De Los Reyes et al., 2015).  

Second this project looked at pre- to post-intervention change and collected measures at 

two timepoints. While pre-post study designs offer advantages, they also pose limitations for 

both internal validity and external validity (Mercer et al., 2007). Specifically, this design can 

decrease threats to internal validity but increase threats to external validity. One concern is 

maturation, where participants improve naturally over time. Additionally, historical events may 

have influenced outcomes. For example, this study was conducted during a change in the United 

States federal leadership and during a time that a member of the current presidential cabinet 

speculated causes to autism. There is concern that this historical event may have influenced 

families’ decision-making about evaluations and affected their stress and knowledge levels 

outside of the content taught in the intervention. Lastly, there are expectancy effects with 

pre/post designs, where participants might improve simply because they are receiving a service 

(Nock & Kazdin, 2001; Walter & Gilmore, 1973).  

Another limitation of this study involves two of the outcome measures used. The PKQ 

measure, while relevant and adapted to the intervention content, is a non-validated and non-

norm-referenced tool developed by Dahiya et al. (2021), limiting confidence in the precision and 

generalizability of its scores. Similarly, the BPS measure is a validated instrument, but it lacks 

established norm-referenced scoring for interpretation, which constrains interpretation in relation 

to a representative population. The absence of norm-referenced data for these measures reduces 

the ability to benchmark caregiver outcomes against broader clinical or population-based 

standards. Future research should consider incorporating validated, norm-referenced instruments 

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or further developing and validating the PKQ and BPS to strengthen interpretability and 

comparability to a norming group.  

Future Research 

Sample Size and Engagement 

Future research should increase recruitment efforts to recruit a more diverse and 

representative sample. Expanding recruitment efforts and securing additional resources (e.g., 

funding, time, or research assistants) could help address the limitations of sample size and 

enhance the generalizability of findings. For example, providing financial compensation might 

incentivize caregivers to enroll and remain in the research study. Researchers might consider 

expanding recruitment to more clinics from various geographic regions, including rural, urban, 

and suburban territories. Additionally, researchers might partner with community-based 

organizations to recruit through their networks. Future efforts to increase engagement might 

include offering brief informational sessions on the parent training program, testimonials from 

other caregivers who participated in past research, providing flexible scheduling options versus 

picking the dates the programs will be run, and increasing communication timepoints during 

recruitment.  

Measurement and Design 

Future studies should consider collecting data at additional timepoints to progress 

monitor changes in the dependent variables being studied. Future studies might also explore the 

long-term maintenance of behavior changes following the intervention. For example, a 

longitudinal study could measure improvements in behavior intensity maintained at a 6-month or 

12-month follow-up. To take it a step further, future researchers might develop a study that uses 

a correlational design or quasi-experimental design to see if caregivers require fewer intervention 

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services post-evaluation because of their participating in the C-HOPE parent training program. 

Multiple components taught in the C-HOPE parent training program are taught in other 

interventions. It could be hypothesized that receiving this information in advance would help 

families jump into intervention post-evaluation quicker and more easily or not require services at 

all.  

Lived Experiences 

Future iterations of the C-HOPE intervention might integrate caregivers’ lived 

experiences. Caregivers could potentially serve in a co-facilitator role, co-leading sessions with a 

trained clinician or interventionist. This co-treatment model may help normalize the challenges 

faced by participating caregivers and provide a sense of shared understanding outside of the 

perspective that the interventionist provides, which could enhance the overall acceptability and 

relatability of the intervention. Research on peer-to-peer support programs underscores the 

benefits of shared lived experience in building trust, increasing motivation, and enhancing 

engagement in parent-focused interventions (e.g., Kaiser et al., 2022). 

While caregivers may not be equipped to independently deliver the full curriculum 

without additional training or clinical supervision, components of the intervention (e.g., sharing 

personal experiences, modeling strategy use, or facilitating group discussion) could be 

effectively led by experienced caregiver peers. To determine feasibility, it would be useful to 

pilot a model in which caregivers co-lead under supervision, with clear delineation of roles and 

support (e.g., training, manual, and fidelity checklists). 

Participant Enrollment 

Future research should also investigate potential differences between families who enroll 

in the C-HOPE intervention and those who do not. Understanding the characteristics of non-

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participating families and comparing them to enrolled families may help identify potential 

barriers to engagement and ensure equitable access to services. For example, families who face 

greater logistical challenges (e.g., work schedules, transportation), language barriers, or 

caregiving burdens may be less likely to participate, despite having equal or greater need for 

support than those without similar challenges. Systematically comparing demographic variables, 

perceived stress levels, child behavior severity, and service navigation experiences between 

participants and non-participants could help clarify what families are being reached for this 

intervention. This line of future research can also be advantageous for informing adaptations that 

enhance the accessibility and uptake of parent training programs such as C-HOPE.  

Procedures 

Future research studies might further explore strategies to engage participants and 

improve attendance. Additional strategies, such as sending more frequent reminders (e.g., mid-

week emails, phone calls, or text messages) or using digital platforms for automated 

notifications, may increase engagement. Future researchers could also experiment with different 

types of reminders, such as brief motivational messages or reminders emphasizing the relevance 

of each session, to boost participation and adherence to the study protocol. 

A limitation highlighted in the study was a change in interventionists. Future research 

should continue to use fidelity checklist and consider further controlling for these differences by 

making sure interventionist implementation remains constant across groups, as well as the 

modality.  

It is noteworthy to mention that there were not meaningful differences in outcomes across 

groups one and two (adapted C-HOPE) compared to three (fully virtual adapted C-HOPE). It is 

possible that a fully online version is potentially indicated, given that findings did not differ and 

125 

 
 
 
 
previous C-HOPE studies (e.g., Kuravackel et al., 2017; Rogers et al., 2018) provided the 

intervention virtually. Once initial efficacy is established, future research might compare in-

person, hybrid, and fully virtual formats of the adapted C-HOPE intervention. Comparing each 

of these unique modalities would provide information about whether the intervention would have 

similar effects across various modalities. It could also provide valuable information on which 

modality is preferred for caregivers who have children who are waiting for an evaluation for 

autism. This information could identify caregiver preference, as well as identify which modality 

provides the strongest change in outcomes on caregiver stress, knowledge, efficacy and 

satisfaction, and child behavior.  

Two caregivers reported scores in the elevated stress range after completing the study. 

Given these findings, it might be relevant to include additional material about stress reduction 

techniques. Stress-reduction techniques were taught in two sessions and then reiterated 

throughout the intervention. It might be beneficial to identify additional tools or have caregivers 

complete assignments on stress reduction to increase the dosage of this content. Further, future 

research studies might consider personalizing stress reduction techniques to the preferences of 

the caregivers, to make the strategies more acceptable and feasible. The interventionist might 

ensure an objective of session five (i.e., peer-to-peer coaching) is to incorporate personalized 

stressed reduction techniques, while asking caregivers their favorite stress reduction techniques 

they used. 

Potential Adaptations Informed by Caregiver Feedback. As highlighted in the focus 

group, caregivers shared that they wanted more information on autism as they were in a period of 

trying to understand what Autism is and if their child has it. Specifically, caregivers found the 

126 

 
 
 
 
theories of autism to be interesting and they wanted to know more about brain function, 

including how children with autism interact with the world.  

An enhancement for future studies would be the development of a resource packet for 

families, particularly focused on autism education, while still clearly explaining that the 

program’s goal is not to provide a diagnosis of autism but rather to provide parents with trusted 

information as they prepare for a comprehensive evaluation to rule out this diagnosis for their 

child. This resource packet can serve as a guide for families to personally seek out relevant 

information on autism, empowering them with additional knowledge while still maintaining the 

focus on the stress reduction and behavioral strategies offered in the program. Clear 

communication about the distinction between autism-related resources and the program’s 

behavioral focus may improve caregiver expectations and reduce confusion. 

Implications for Practice 

There are a multitude of applications to clinical practice. First, and foremost, caregiver 

participants reported that they valued the intervention as evidenced by the high ratings provided 

on the acceptability measure and in the focus group. Caregivers appreciated the opportunity to 

connect with other caregivers who shared similar experiences, suggesting the importance of peer 

support for caregivers who are waiting for an evaluation for their child. Clinicians might 

consider integrating peer-support elements into group-based parent training programs to foster a 

sense of community and provide a platform for practicing strategies collaboratively. This 

approach could enhance the overall efficacy and satisfaction of the intervention for caregivers of 

children awaiting an ASD evaluation. 

Next, acquiring knowledge about behavioral principles during the waitlist period may be 

critical for early behavioral intervention after a diagnosis is made. Rather than waiting to get 

127 

 
 
 
 
services post-evaluation, caregivers can begin to apply evidence-based strategies immediately, 

potentially reducing the severity of behavioral challenges and improving both child and caregiver 

outcomes during a time when formal services are often not yet available. Increasing parent 

knowledge has many implications for both caregiver and child outcomes. More knowledgeable 

caregivers are often better equipped to implement strategies with fidelity, engage in collaborative 

problem-solving with professionals, and advocate for their child’s needs during and after the 

diagnostic process (e.g., Gunderson et al., 2022). Thus, caregivers might be more equipped to 

jump into services post-evaluation, too.  

Parent training programs that emphasize clear, structured education on behavior management 

(e.g., reinforcement, antecedents, planned ignoring) can empower caregivers and promote better 

child outcomes. In addition, anecdotally, caregivers reported that they appreciated the 

individualized BIP with parenting strategies as a key part of the intervention. Clinicians can 

leverage this feedback to develop or enhance current interventions for caregivers of children 

awaiting an ASD evaluation. Moreover, clinicians can consider adapting their current services to 

include individualized behavior plans that incorporate a child’s strength and challenges into the 

plan.  

Fourth, mixed-modality (pre-recorded modules, telehealth, and in-person) intervention 

delivery has the benefit of increasing access to interventions where families are commonly not 

able to access them. These factors should be considered when clinicians offer families support 

while on a waiting list for evaluations for autism.  

Finally, the adapted C-HOPE intervention has potential to support individuals in the 

broader neurodevelopmental community. At present, there is initial evidence to suggest that C-

HOPE can support both caregivers of children diagnosed with autism and those that are waiting 

128 

 
 
 
 
for an evaluation from autism and are showing signs of social communication difficulties. Parent 

training is a well-established intervention for caregivers of neurodevelopmental disorders (e.g., 

Tan-MacNeill et al., 2021). If children of those caregivers are having difficulty with problem 

behavior, participation in the C-HOPE intervention might be suitable to support their needs given 

its recognition of individualizing care.  

Implications for School Psychologists 

The adapted C-HOPE intervention might offer a feasible framework for how school 

psychologists can mitigate disparities for families in accessing parent training support for 

caregivers of children awaiting an evaluation for autism. School psychologists are uniquely 

positioned within educational systems to serve as liaisons between families and external 

diagnostic services (e.g., Gordon-Lipkin et al., 2016). In clinical contexts, caregivers often are 

not able to access intervention until they receive a diagnosis for their child, which allow 

clinicians to bill for the service (Knapp & VandeCreek, 2008). In schools, there is more 

flexibility in the services that can be provided because school psychologists are not constrained 

by billing requirements. In addition, schools offer an opportunity to engage a broad group of 

caregivers as the caregivers would not need to initiate or seek out this service. This might reduce 

disparities and expand reach to more caregivers. For example, school psychologists might offer 

the service as part of an after school program for caregivers. Alternatively, school psychologists 

might recommend the program to caregivers while they are waiting for their child’s school-based 

special education evaluation, which often takes 30 days or longer.  

Overall, the results of this study demonstrate initial promise for the efficacy of C-HOPE 

for caregivers of children waiting for an autism evaluation. While the sample size is small, there 

are possible implications that evaluating this intervention with a larger sample would provide 

129 

 
 
 
 
encouraging data. Initial findings highlight that participation in C-HOPE can reduce caregiver 

stress, increase caregiver efficacy and satisfaction, increase knowledge about behavioral 

principles and behavior management, and reduce child behavior.  

130 

 
 
 
 
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prevalence of autism and other developmental disabilities following questionnaire 
changes in the 2014 National Health Interview Survey. National Health Statistics 
Reports, 87, 1- 20.   

Zaidman, Z. A., Mirenda, P., Zumbo, B. D., Wellington, S., Dua, V., & Kalynchuk, K. (2010). 
An item response theory analysis of the Parenting Stress Index-Short Form with parents 
of children with autism spectrum disorders. Journal of Child Psychology & Psychiatry, 
51(11), 1269–1277. https://doi-org.proxy2.cl.msu.edu/10.1111/j.1469-
7610.2010.02266.x  

Zwaigenbaum, L., Bauman, M. L., Stone, W. L., Yirmiya, N., Estes, A., Hansen, R. L., ... & 

Wetherby, A. (2015). Early Identification and Interventions for Autism Spectrum 
Disorder: Executive Summary. Pediatrics, 136(Supplement 1), S1-S9. doi: 
10.1542/peds.2014-3667C  

Zuckerman, K. E., Lindly, O. J., & Sinche, B. K. (2015). Parental Concerns, Provider Response, 

and Timeliness of Autism Spectrum Disorder Diagnosis. Journal of Pediatrics, 166(6), 
1431– 1439. https://doi.org/10.1146/annurev-immunol-032713-120240.Microglia  

Zuckerman, K., Lindly, O. J., & Chavez, A. E. (2017). Timeliness of Autism Spectrum Disorder 
Diagnosis and Use of Services Among U.S. Elementary School-Aged Children. 
Psychiatric services (Washington, D.C.), 68(1), 33–40. 
https://doi.org/10.1176/appi.ps.201500549  

147 

 
 
 
 
 
 
 
 
 
 
APPENDIX A: DEMOGRAPHIC FORM 

Directions: Please complete the following form as completely as possible. Please answer all 
questions truthfully. This information is being collected for research purposes only. Your 
information will be kept confidential and will not be shared in any way by the research team.  

Child Information  

1.  Please indicate your child’s gender:   M 

F 

Other  

2.  What is your child’s birthdate? (MM/DD/YYYY) _______________  

3.  Is your child of Spanish, Hispanic, or Latino origin?  
a.  Yes  
b.  No  
c.  Don’t Know  

4.  What best describes your child’s race/ethnicity? (check all that apply)  

______ White  
______ Black/African American  
______ American Indian or Alaska Native  
______ Asian Indian  
______ Chinese  
______ Filipino  
______ Japanese  
______ Korean  
______ Vietnamese  
______ Asian (not specified elsewhere)  
______ Native Hawaiian  
______ Pacific Islander  
______ Other  

5.  Has a doctor, nurse, psychologist, or other medical/school professional told you that your 

child has (yes/no/don’t know for each option):   

a.  a developmental delay  
b.  autism/autism spectrum disorder  
c.  a learning disability  
d.  attention deficit/Hyperactivity Disorder (ADHD or ADD)  
e.  a cognitive impairment  
f.  a hearing impairment  
g.  a visual impairment   
h.  epilepsy or seizures  
i.  anxiety  
j.  depression  
k.  another emotional disorder (such as bipolar disorder; please describe)  
l.  an emotional or behavioral disturbance  

148 

 
 
 
 
 
  
  
  
  
  
  
6.  Does your child currently receive any services?     Yes  

No   

7.  If you answered “yes” to #11 please select all that apply:   
a.  ______ Academic Tutoring   
b.  ______ Counseling   
c.  ______ Occupational Therapy   
d.  ______ Physical Therapy   
e.  ______ Psychological Services   
f.  ______ Social Work Service   
g.  ______ Speech and Language Therapy   
h.  ______ Other (Please specify) _______________________________   

Caregiver Information  

8.  What is your birthdate? _________________________  

9.  Please indicate the option that best describes your gender identification:   
a.  Male  
b.  Female   
c.  Nonbinary  
d.  Prefer to self-describe. If so, how? _________________  

10. Are you of Spanish, Hispanic, or Latino origin?  
a.  Yes  
b.  No  
c.  Don’t Know  

11. What best describes your race/ethnicity? (check all that apply)  
a.  ______ White  
b.  ______ Black/African American  
c.  ______ American Indian or Alaska Native  
d.  ______ Asian Indian  
e.  ______ Chinese  
f.  ______ Filipino  
g.  ______ Japanese  
h.  ______ Korean  
i.  ______ Vietnamese  
j.  ______ Asian (not specified elsewhere)  
k.  ______ Native Hawaiian  
l.  ______ Pacific Islander  
m.  ______ Other  

12. Click any medical condition that a doctor, nurse, psychologist, or other medical/school 

professional told you that you have:   

a.  a developmental delay  
b.  autism/autism spectrum disorder  

149 

 
 
 
 
  
  
  
  
  
  
  
c.  a learning disability  
d.  attention deficit/Hyperactivity Disorder (ADHD or ADD)  
e.  a cognitive impairment  
f.  a hearing impairment  
g.  a visual impairment   
h.  epilepsy or seizures  
i.  anxiety  
j.  depression  
k.  another emotional disorder (such as bipolar disorder; please describe)  
l.  an emotional or behavioral disturbance  

13. What describes your highest level of education?  
a.  ______ Some high school  
b.  ______ High school diploma  
c.  ______ College/university degree  
d.  ______ Some graduate school  
e.  ______ Graduate degree (master’s level or higher)  

14. Please indicate your marital status:  
a.  ______Single  
b.  ______Married  
c.  ______Living with domestic partner  
d.  ______Divorced  
e.  ______Widowed  

15. Besides the child participating in this study, how many children are living in your home?  
a.  1  
b.  2   
c.  3   
d.  4  
e.  5  
f.  6  
g.  7+  

16. How many of these children are biological and/or adoptive siblings to your child?   
a.  1  
b.  2   
c.  3   
d.  4  
e.  5  
f.  6  
g.  7+  

17. Do any of these children have a medical condition that a doctor, nurse, psychologist, or 

other medical/school professional told you that you have?  

a.  a developmental delay  

150 

 
 
 
 
  
  
  
  
  
b.  autism/autism spectrum disorder  
c.  a learning disability  
d.  attention deficit/Hyperactivity Disorder (ADHD or ADD)  
e.  a cognitive impairment  
f.  a hearing impairment  
g.  a visual impairment   
h.  epilepsy or seizures  
i.  anxiety  
j.  depression  
k.  another emotional disorder (such as bipolar disorder; please describe)  
l.  an emotional or behavioral disturbance  
m.  none   

18. Thinking about all the sources of income you and your family received, what was the 

total gross income (before taxes were taken out) for your household over the past year:  

_____a) $5,000 or less  
_____b) $5,001 to $10,000  
_____c) $10,001 to $15,000  
_____d) $15,001 to $20,000  
_____e) $20,001 to $30,000  
_____f) $30,001 to $35,000  
_____g) $35,001 to $40,000  
_____h) $40,001 to $50,000  
_____i) $50,001 to $75,000  
_____j) $75,001 to $100,000  
_____k) $100,001 to $200,000  
_____l) $200,001 or more  

 Services Information  

1.  On what date did you request an evaluation? 

(MM/DD/YYYY)  _________________________  

2.  Is this an initial evaluation?  
a.  Yes  
b.  No   

3.  Select the option below that best represents the nature of the evaluation  
a.  Autism spectrum disorder evaluation only   
b.  Autism spectrum disorder evaluation and another evaluation  

i. 

Please specify: __________________  

4.  By whom did you request an evaluation?  
a.  Pediatrician  

151 

 
 
 
 
  
  
  
   
  
  
  
  
b.  Psychologists  
c.  Other medical doctor   

5.  How long have you been waiting for an evaluation?  
a.  0 to 1 month  
b.  1 to 2 months  
c.  2 to 3 months  
d.  3 to 4 months  
e.  4 to 5 months  
f.  5 to 6 months  
g.  6 to 7 months  
h.  7 to 8 months  
i.  8 to 9 months   
j.  9 to 10 months   
k.  10 to 11 months   
l.  11 to 12 months   
m.  12+ months   

6.  Approximately how long did the clinic say you would be on the evaluation waiting list?   
a.  0 to 1 month  
b.  1 to 2 months  
c.  2 to 3 months  
d.  3 to 4 months  
e.  4 to 5 months  
f.  5 to 6 months  
g.  6 to 7 months  
h.  7 to 8 months  
i.  8 to 9 months   
j.  9 to 10 months   
k.  10 to 11 months   
l.  11 to 12 months   
m.  12+ months  

i. 

If 12+ months, approximately how many months? ____________  

 Services Information  

1.  What types of services would you find most valuable during this time? (check that all 

apply)  

a.  Psychological services for myself  
b.  Psychological services for my child  
c.  Behavioral services for my child   
d.  School-based services for my child  
e.  Other (please explain):  

152 

 
 
 
 
  
  
  
  
APPENDIX B: PARENT KNOWLEDGE QUESTIONNAIRE 

Name:________________________________ Date:________________  

Please rate how knowledgeable you are in each of these areas as it relates to your child’s primary behavioral problem.  

Not Very Much                                      Very Much  
1.................. 2 .....................3 .....................4  

How much do I know about this area? 

How behavioral strategies can help address my child’s behavior.  
How different clinicians and treatments may impact the way my child learns.  
How and why my child may think or behave in certain ways.  
How to determine the reasons or motives behind my child’s behavior.  
How to decrease negative behavior in my child.  
How to increase positive behavior in my child.  
How to use visual supports to increase my child’s understanding of expectations.  
How to identify and implement reinforcements to improve my child’s behavior.  
How to identify environmental challenges that will interfere with my child’s 
behaviors and use prevention strategies.  
How to explain to others what supports help my child perform their best.   
How to explain to others what environmental challenges will interfere with my 
child’s behaviors.  
How to utilize effective commands with my child to improve compliance.  
How to utilize consistency with my child.  
How to assess possible causes of my child’s problem behaviors (ABC’s of 
behavior).  
How to develop a behavior plan to address my child’s problem behaviors.   
How to use data to monitor my child’s progress and re-evaluate goals.  
How to teach new skills to my child.   

1 
1 
1 
1 
1 
1 
1 
1 
1 

1 
1 

1 
1 
1 

1 
1 
1 

2 
2 
2 
2 
2 
2 
2 
2 
2 

2 
2 

2 
2 
2 

2 
2 
2 

3 
3 
3 
3 
3 
3 
3 
3 
3 

3 
3 

3 
3 
3 

3 
3 
3 

4 
4 
4 
4 
4 
4 
4 
4 
4 

4 
4 

4 
4 
4 

4 
4 
4 

153 

 
 
 
 
  
  
  
  
 
 
 
 
 
 
APPENDIX C: AIM/IAM/FIM 

Response Scale: 1 = Completely disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = 
Agree, 5 = Completely agree Scoring Instructions: Scales can be created for each measure by 
averaging responses. Scale values range from 1 to 5. No items need to be reverse coded. 

Acceptability of Intervention Measure (AIM) 

Completely 
disagree 
1 

1 

1 
1 

Disagree 

2 

2 

2 
2 

Neither agree 
nor disagree 
3 

3 

3 
3 

Agree 

4 

4 

4 
4 

Completely 
agree 
5 

5 

5 
5 

Intervention Appropriateness Measure (IAM) 

Completely 
disagree 
1 

1 

1 

1 

Disagree 

2 

2 

2 

2 

Neither agree 
nor disagree 
3 

3 

3 

3 

Agree 

4 

4 

4 

4 

Completely 
agree 
5 

5 

5 

5 

Feasibility of Intervention Measure (FIM) 

Completely 
disagree 
1 

Disagree 

2 

Neither agree 
nor disagree 
3 

Agree 

4 

Completely 
agree 
5 

C-HOPE 
meets my 
approval 
C-HOPE is 
appealing to 
me 
I like C-HOPE 
I welcome C-
HOPE 

C-HOPE 
seems fitting 
C-HOPE 
seems suitable 
C-HOPE 
seems 
applicable 
C-HOPE 
seems like a 
good match 

C-HOPE seems 
implementable 

154 

 
 
 
 
 
 
 
 
 
 
C-HOPE seems 
possible 
C-HOPE seems 
doable 
C-HOPE seems 
easy to use 

1 

1 

1 

2 

2 

2 

3 

3 

3 

4 

4 

4 

5 

5 

5 

155 

 
 
 
 
APPENDIX D: PROCEDURAL FIDELITY FORMS 

Session 1 
Pre-Recorded Online Module  

Instructions: Below are components of the session 1. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session 
o  Reviewed the philosophy of COMPASS using the balance 
o  Explained the outcomes of COMPASS for Hope (C-HOPE) 
o  Reviewed the COMPASS profile 
o  Outlined how to prioritize and identify a behavior problem to address 
o  Explained how to use the ABC form 
o  Explained how to use the Weekly Behavior Form 
o  Discussed ideas on how to remember to complete the forms 
o  Discussed what to expect for the first individual in-person session 

•  The session incorporated:  

o  Checklists that are used to help organize information, identify child’s needs, and 

solicit input from parents 

o  Facilitated guidance and structure from the therapist  

•  The behavior that was identified for tracking is: 

o  Described in clear behavioral terms 
o  Observable  

•  The child’s ability to learn is based on environmental and child factors: 

o  The philosophy of the environment as an important factor for child progress was 

discussed 

o  The caregiver completes and discusses COMPASS forms on child’s 

strengths/challenges and environment’s strengths/challenges  

156 

 
 
 
 
 
 
 
Session 2 
Pre-Recorded Online Module  

Instructions: Below are components of the session 2. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session and an overview of the upcoming sessions 
o  Discussed the role that child problem behavior has on parent stress and parenting 

skills 

o  Discussed the ABC’s of behavior 
o  Discussed reinforcement and punishment means  
o  Discusses the COMPASS model that says children can be competent when their 

challenges are balanced by supports  

o  Reviewed expectations, roles, confidentiality  
o  Presented a relaxation strategy 
o  Asked to fill out the satisfaction survey 

•  The session incorporated:  
o  ABC’s of behavior  
o  Relaxation strategy  

157 

 
 
 
 
 
 
 
Session 3 
Individual Meeting  

Instructions: Below are components of the session 3. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session and an overview of the upcoming session 
o  Reviewed the COMPASS for Hope philosophy on behavior  
o  Helped me identify the target behavior and a replacement behavior  
o  Discussed child’s behavior plan specifically  
o  Problem solved any issues that might be related to implementing the behavior 

plan 

o  Asked to fill out the satisfaction survey 

•  The session incorporated:  

o  An activity to create a visual support for my child  
o  Relaxation strategy  

158 

 
 
 
 
 
 
 
Session 4 
Group Meeting  

Instructions: Below are components of the session 4. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session and an overview of the upcoming session 
o  Reviewed the COMPASS for Hope philosophy on behavior  
o  Discussed the typical and delayed development and how parenting strategies need 

to match the child’s level of maturity  

o  Discussed understanding of behavior using an iceberg model 
o  Explained what a functional assessment of behavior means 
o  Helped me review me ABC chart and think about a replacement skill for the 

negative behavior  

o  Helped me identify my child’s personal and environmental challenges and 

strengths  

o  Reminded me of being consistent in the use of my strategies  
o  Shared information about visual supports  
o  Discussed how to make clear commands  
o  Discussed strategies to try to prevent problem behavior  
o  Presented a relaxation strategy 
o  Asked to fill out the satisfaction survey 

•  The session incorporated:  

o  An activity to create a visual support for my child  
o  Had me identify one strategy to help cope with stress  
o  Relaxation strategy  
o  Handouts to help understand the topics today  

159 

 
 
 
 
 
 
 
Session 5 
Group Meeting  

Instructions: Below are components of the session 5. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session and an overview of the upcoming session 
o  Facilitated group discussion  

•  The group 

o  Came prepared with their case conceptualization datasheet filled out 
o  Discussed their child and their behavior plan  

•  The session incorporated:  

o  Reviewing other caregiver’s behavior plans  
o  Relaxation strategy  

160 

 
 
 
 
 
 
 
Session 6 
Individual Meeting  

Instructions: Below are components of the session 6. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session and an overview of the upcoming session 
o  Discussed the child’s behavior plan specifically 
o  Discussed strategies for coping with stress 
o  Problem solves issues related to implementing the behavior plan  

•  The group 

o  Came prepared with their case conceptualization datasheet filled out 
o  Discussed their child and their behavior plan  

•  The session incorporated:  
o  Relaxation strategy  

161 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Session 7 
Focus Group 

Instructions: Below are components of the session 7. Check the following boxes for the elements 
that occurred during the sessions  

•  The therapist 

o  Explained the purpose of the session  
o  Discussed the questions  
o  Guided the group in answering the questions  

•  The group 

o  Provided a response to each question, if desired  

•  The session incorporated:  

o  Audio recording of session  

162 

 
 
 
 
 
 
 
 
 
 
APPENDIX E: POST-SESSION QUESTIONNAIRE 

1.  Did your child receive any mental health, medical, or additional service related to your 

child between the last session and this session? If so, what services?   

a.  Mental health  
b.  Medical   
c.  School-based   
d.  Other (if so, please explain): _______________________________  

2.  Did you receive any mental health, medical, or additional service related to you between 

the last session and this session? If so, what services?   

a.  Mental health  
b.  Medical   
c.  Other (if so, please explain): _______________________________  

163 

 
 
 
 
 
  
 
APPENDIX F: FOCUS GROUP QUESTIONS 

•  As a caregiver of a child who is waiting for an autism evaluation, what are the primary 

services and supports you want during this time?  

•  What were some strengths to the C-HOPE intervention?  
•  What were some weaknesses to the C-HOPE intervention?  
•  Suppose that you were in charge and could make a couple of changes that would make 

the program better. What would you do?   

•  Of all the things we've talked about, what was most important to you?  
• 

If you were inviting a friend to participate in another C-HOPE intervention, what would 
you say in the invitation?  

164 

 
 
 
 
  
  
APPENDIX G: COMPASS PROFILE 

165 

 
 
 
 
 
166 

 
 
 
 
 
167 

 
 
 
 
 
168 

 
 
 
 
169 

 
 
 
 
 
COMPASS Profile Summary and Behavior Intervention Plan (BIP) Template 

Targeted Behavior:  

Probable Purpose(s):  

New Skills to teach:  

Challenges (for teaching the new 
skill):  

Support (for teaching the new 
skill):  

Environmental Challenges to be 
Made:  

Adult Changes to be Made:  

Modifications/Adaptation/Support 
to put in Place:  

Specific Teaching Strategies:  

Planned Reaction when Behavior 
Does Occur:  

Planned Reaction when Behavior 
Does Occur:  

170 

 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
APPENDIX H: SESSION 5 FORM 

Child 

Age 

Sex 

Race/Ethnicity 

Strengths (1-3) 

Challenges (1-3) 

Target behavior 

Child Strategies  

Caregiver strategies for dealing with stress 

Progress – how are things going? 

Questions for the group (1-2 or none)  

1. 

2. 

3. 

1. 

2. 

3. 

1. 

2.  

171 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
APPENDIX I: FOCUS GROUP CODE BOOK 

Caregiver Codes 

Parent Stress 

Description: The emotional and psychological challenges caregivers expressed 
while waiting for their child's autism evaluation, including feelings of anxiety, 
frustration, and overwhelm. 

Support Needs 

Description: The specific types of assistance and resources parents require to 
manage their child's needs and their own well-being during the evaluation 
waiting period. 

Personal 
Growth and 
Parent 
Journey 

Personal 
Reflection 

Child Codes 

Description: The developmental process parents experience as they adapt to 
the challenges of raising a child with potential autism, including gaining new 
skills, insights, and resilience. 

Description: The process by which parents evaluate their own experiences, 
feelings, and actions related to their child's behavior and their parenting 
strategies. 

Child 
Behavior 

Description: The various behaviors exhibited by the child, including the target 
behavior addressed in C-HOPE and additional behaviors.  

Program Codes 

Program 
Strength (+) 

Description: The effective components and positive aspects of the parent 
training program that contribute to its success in supporting parents and 
improving child outcomes. 

Program 
Weakness (-) 

Description: The limitations about the parent training program that may affect 
its effectiveness or accessibility for some families. 

Program 
Structure  

Description: Any comment on the structure of the program, including 
modality, time, schedule, length of sessions, etc. 

Community 
and Support 

Description: Any comment that discusses the emotional, social, and practical 
support that families felt (or did not feel) while apart of the group. 

Resources 

Description: The materials, tools, and information provided to the caregivers in 
the program to help them understand autism, manage their child's behavior, and 
navigate the evaluation process. 

Area for 
Improvement 

Description: Any comment on an area for improvement that is outside of a 
strength or a weakness (if so, "program weakness" or "program strength" 
instead) 

172 

 
 
 
 
 
BIP Codes 

Behavior 
Intervention 
Plan  

Description: Any comment on their BIP, including the BIP overview they were 
provided, any modifications to the BIP, strengths and weaknesses of the BIP 

Strategies 

Description:  Any comment about the intervention strategies 

Generalization 
of Strategies 

Description:  Any comment on how they are generalizing the intervention 
strategies to other areas of their child's life 

Description: Any comment on the importance of maintaining regular and 
predictable routines, interventions, and responses to support the child's 
development and reduce behavioral issues. 

Consistency 

Autism Codes 

Autism 
Education 

Description: Any comment in which a caregiver expressed wanting more 
information about ASD or an ASD evaluation. 

Additional Codes 

Evaluation 
and Diagnosis  

Diversity, 
Equity, & 
Inclusion 

Other Codes 

Other   

Random  

Description: Any comment about the evaluation.  

Description: Any comment about DEI-related topic (e.g., wanting more 
culturally relevant strategies). 

Description: Any comment that does not fit a code above but you feel is 
important. Write "other" and then add keywords 

Description: A random statement that does not contain a code (e.g., "Yes, I ate 
my dinner" or "I’ll be right back"). Instructions given by Shelby. Greetings 
(i.e., hello and goodbye). Statements like "um" and "yeah." 

Instruction 

Description: Any statement that feels like an instruction or a question posed by 
the facilitator 

173 

 
 
 
 
APPENDIX J: CASE EXAMPLE #1 

  Participant: Group 2, Parent 1  

COMPASS PROFILE  
Likes, Strengths, Frustrations, Environmental Supports,   
and Environmental Challenges   

The information you provide is vital in understanding how to build a competency model for your 
child/student.  

Likes and Strengths  
Likes:  

•  Likes her iPad and solitary activities  
•  Loves animals (dogs, horses)  
•  Enjoys language classes (Spanish, Arabic, French)  

Strengths:  

•  Talented artist; enjoys drawing on everything  
•  Strong in logical aspects of math  
Independent; prefers being alone  
• 
•  Can be kind  

Frustrations and Fears  
Frustrations:  

Fears:  

•  Easily frustrated by excessive questioning or demands for reciprocal conversation  
•  Dislikes playing with others, especially if it requires ongoing engagement  
•  Avoids crowds; prefers headphones or drawing in busy settings  

•  Fears abandonment and feeling inadequate  
•  Follows routines but struggles with hygiene tasks, even when they’re part of her 
routine  
•  Tests limits; obsessed with time  
•  Supports that make learning successful include:  

Environmental Supports  
Supportive and Observant Caregivers:  

•  Caregivers are highly attuned to her emotional states and triggers.  
•  They have already identified effective strategies like providing headphones and 
visual tools to support regulation.  

Structured Home Environment:  

•  She thrives on routine and consistency, and the home environment supports this 
by maintaining predictable daily activities (e.g., routines around hygiene, even if 
partially followed).  

Use of Preferred Tools and Activities for Regulation:  

•  She has access to preferred activities such as drawing and her iPad, which help 
her self-soothe and regulate emotions.  

174 

 
 
 
 
  
  
  
  
  
Recognition of Learning Style:  

•  Caregivers understand she learns best visually and provide written or visual 
instructions to support her memory and comprehension.  

Environmental Challenges  
Social Interactions:  

•  Difficulty with reciprocal interaction and interpreting jokes  
•  Mimics peers but can escalate or be perceived as rude  
•  Repetitive hand-raising in class  

Communication:  

•  Difficulty speaking fluidly; sometimes misunderstood  
•  Cries or wails when overwhelmed  
•  Avoids seeking help from adults  
•  Diagnosed with dyspraxia (motor planning difficulty)  

Learning Skills:  

•  Learns best visually; benefits from doodling  
•  Needs written instructions; poor short-term memory  
•  Follows rules if presented clearly  

Summary of Concerns  

•  Meltdowns have become socially unacceptable and embarrassing  
•  Needs support expressing emotions appropriately and coping with transitions  

175 

 
 
 
 
  
  
  
  
 
Behavior Intervention Plan (BIP) 

Targeted 
Behavior: 

Tantrums  

Defined: Crying, wailing, and throwing things 

Probable 
Functions to 
Behavior(s): 

Attention 

Escape  

New 
Behavior to 
teach: 

The new behavior to teach is helping your daughter identify a coping strategy to use when feeling negative 
emotions, including frustration, anger, or sadness.  

Challenges  

Personal  

(for 
teaching the 
new skill): 

•  Reciprocal communication 
•  Challenges with communicating needs 
•  Emotion regulation 

Environmental  

•  School is not always structured to her learning styles  

Support  

Personal  

(for 
teaching the 
new skill): 

Independent  

• 
•  Academically motivated  
•  Creative and artistic  

176 

 
 
 
 
  
 
 
  
Environmental  

•  Enjoys a variety of activities  

Environmen
tal/Adult 
Strategies to 
Use: 

Planned 
Reaction 
when 
Behavior 
Does Occur: 

•  Praise for good all good behavior you see with your daughter (e.g., she chose to take deep breaths, she 

problem-solved, she labeled how she was feeling)  

•  Practice conflict resolution and problem solving (e.g., the process flowchart below) when she is in a state of 
calm. Allow her to practice using strategies to calm down, which might help her to remember to use them 
when she is in a state of not being calm. Model how to use these strategies (e.g., “when I am upset with my 
friend, I tend to take 3 deep breaths and then let them know why I am upset.”)  

Positive Reinforcement: If she uses an adaptive strategy, provide her with verbal labeled praise! Example #1: wow, 
I love how you chose a strategy to help yourself calm down  

Example #2: I really like how you chose a coping strategy to help yourself calm down  

Example #3: I could tell you were really upset and you did a fabulous job going through your problem solving 
process  

Respond Successfully: Remember, your response to their behavior matters. If you respond with the same intensity, 
it is likely that your child will not feel supported and it with further exacerbate their dysregulation. If you respond 
with warmth, understanding, and encouragement, it is likely that you child will feel supported.  

Respond with a supportive statement + an idea  

For example: “I sense you are feeling frustrated right now and that can be hard (supportive statement) + I wonder if 
you might want to go try out a strategy from your tool box (an idea) 

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For example: “It looks like you are upset and that probably does not feel good (supportive statement) + I think 
practicing a coping strategy might help (an idea) 

Planned Ignoring: To handle major tantrums, try to ignore the behavior when possible. Let her know that you’re 
available to talk when she’s calm, and offer support in problem solving and finding a coping strategy. If the tantrum 
persists, continue to ignore the behavior until she can demonstrate a calm demeanor. Then help her problem solve.  

Alternative Behaviors: If skin picking occurs when using planned ignoring, offer alternative behaviors. An 
alternative behavior is something that can give a child the same internal input but with a different external behavior. 
For example, try out these items:  

•  Example #1 
•  Example #2 
•  Example #3 
•  Example #4 
•  Example #5 

Coping Tool Box: Remind her of relaxation strategies in her coping tool box. You could say, “hey, it looks like you 
are having a tough time right now. I wonder if using your relaxation strategies could be helpful.”  

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What can we do when we are feeling upset? Well, sometimes having a process can help us! Here is a Problem Solving Process you 
can use J 

1. Take 
a deep 
breath

2. 
Practice 
a 
coping 
strategy

3. Still feeling upset? Here are some options: 

Ask an 
adult for 
help to 
work 
through 
the 
problem

Try 
another 
coping 
strategy

Coping Tool Box 

Talk to a 
friend to 
help 
work 
through 
the 
problem 

Go for a 
walk

What are 
some 
other 
options?

Add them 
below

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10 tools to get you started 

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Tool #1 

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Tool #2 

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Tool #3 

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Tool #4 

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Tool #5 

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Tool #6 

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Tool #7 

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Tool #8 

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Tool #9 

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Tool #10 

Coping Strategies Through Art 

a.  Draw with your eyes closed 
b.  Draw what you are feeling on the inside  
c.  Write a letter to the person who made you feel the emotion you are feeling  
d.  Draw yourself as an animal  
e.  Draw yourself as a plant  
f.  Make art for someone else  
g.  Go outside and collect natural materials such as leaves, rocks, dirt, stick, etc. and make art 
h.  Make art out of recycled items  
i.  Paint to music  
j.  Draw something in black & white and then draw the same thing in color Paint to music  

What other strategies can you add to your tool box? 

Add them in the boxes below: 

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APPENDIX K: CASE EXAMPLE #2 

Participant: Group 1, Parent 2  

COMPASS PROFILE  
Likes, Strengths, Frustrations, Environmental Supports,   
and Environmental Challenges   

The information you provide is vital in understanding how to build a competency model for your 
child/student.  

Likes and Strengths  
Likes:  

Legos  
Being creative  

•  Gaming (Nintendo Switch, Mario, Minecraft, Farming Simulator)  
•  Artistic activities (coloring, painting, drawing)  
• 
• 
Strengths  
Creative thinker  
• 
•  Very kind and caring  
• 
• 
• 

“Best big brother” (loves his brother deeply)  
Loves his pets (cat and dog)  
Strong vocabulary and advanced knowledge in topics of interest  

Frustrations and Fears  
Frustrations:  

•  Struggles with reading (especially when video games require reading)  
•  When brother won’t share  
•  Difficulty expressing certain thoughts or needs  

Fears:  

•  Afraid of bugs  
•  Hesitant to go outside  

Environmental Supports  
Supports that make learning successful include:  

•  Positive Routines: Clear morning routines and consistent expectations  
•  Visual Supports: Use of visual schedules and visual timers (e.g., Alexa timer)  
•  Effective Communication Strategies: Simple, direct commands; offering 
choices  
•  Motivators: Built-in rewards (e.g., earning screen time or swim class)  
•  Prompting & Reminders: Warnings about transitions help ease the process  
•  Safe Spaces: Has a safe space. Option to go to his room to calm down when 
overwhelmed  

Environmental Challenges  
Social Interactions with Others:  

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•  Hides behind mom in social settings  
•  Nervous meeting new people  
•  May not initiate speech at school unless prompted  

Communication (Understanding and Expressing Self):  
•  Struggles with asking for help  
•  Does not advocate for himself  
•  Can fixate on negative thoughts without verbalizing needs  

Learning Skills:  

•  Doesn’t ask for help even when he doesn’t understand  
•  Can struggle with multi-step tasks without prompts  

Summary of Concerns  

•  Resistance to transitions (especially school-related)  
•  Emotional dysregulation during undesired activities or changes in routine  
•  Difficulty advocating for himself when confused or overwhelmed  
•  Avoidance behaviors (e.g., hiding, whining, tantrums) as communication  
•  Challenges with social anxiety and separation  

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Behavior Intervention Plan (BIP) 

Targeted 
Behavior: 

Tantrums around transitions  

Defined: having a meltdown/tantrum, being vocally aggressive, and yelling 
when he does not want to transition from a preferred activity to a non-
preferred activity (e.g., going to school).  

Escape  

Probable 
Functions to 
Behavior(s): 

New 
Behavior to 
teach: 

When he is given a command to stop an activity, he will respond by engaging 
in choosing an option to help him transition. For example, vocalizing his 
feelings, doing something physical (e.g., jumping jacks), setting a timer, etc. 

Challenges  

Personal  

(for 
teaching the 
new skill): 

•  Struggling with reading in school and at home (e.g., while playing 

video games or at school).  

•  Difficulty asking for help when he needs help form others (e.g., at 

school when he does not understand something) 

Environmental  

•  Difficulty with school (e.g., difficult time talking in school) 
•  Difficulty when situations change from what he was expecting (e.g., 
was told cousin will be at a party but he was not there, and he had a 
tantrum) 

•  Difficult time going outside (e.g., is afraid of bugs outside) 
•  Difficult time when younger brother does not share with him (i.e., he 
does not understand his brother does it having sharing skills yet) 

•  Difficult time meeting new people (e.g., stays behind mom) 

Support  

Personal   

(for 
teaching the 
new skill): 

•  He is creative 
•  He is a good brother  
•  He is kind  
•  He has a strong vocabulary and advanced knowledge on learned topics 

Environmental   

•  Mom understands consistency and direct commands to be used for 

teaching new skills 

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Environmen
tal/Adult 
Strategies to 
Use: 

•  Likes spending time with family (e.g., spending time with dad doing 

activities with just him [e.g., hiking]). 

•  Use the first-then board  
•  Provide a visual timer (his own personal one that only you use with 

him; tells Amazon Alexa to start timer) 

•  Give choices “Do you want to wrap up now or in 2-minutes” 
• 
• 

Increase his emotional language to help him verbalize how he feels 
Implement a Token Economy positive reinforcement system that 
provides him with a tangible reward after the use of appropriate 
behavior. Specifically, he will receive one token/check mark from an 
adult after completing a transition or task. When all tasks are 
completed, he will earn a predetermined reward based on their interest. 

•  Reinforce appropriate behavior  
•  Practice consistency  

Planned 
Reaction 
when 
Behavior 
Does Occur: 

Planned Ignoring: Avoid giving attention to him when he throws a tantrum 
during transitions. Say “I will talk to you when are calm.” Wait at least 15 
seconds until he has calmed, then say “Thank you for being calm, let’s try 
using XYZ strategy.”  

Positive Reinforcement: If he uses an adaptive strategy, provide him with 
verbal labeled praise! Example #1: wow, I love how you transitioned to 
school. Example #2: you did a really nice job putting down your game and 
then putting your shoes on so we could leave the house. 

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First-Then Schedule for Transitions 

First (write down the activity they are currently doing): 

Set Timer 

Provide them with a physical timer so that they can see the time count down.  

Note: we want it to count downward, not count upward 

Provide verbal statement: “In XX minutes, we will transition to YY”; Provide 1-minute 
warning, if helpful 

Then (write the upcoming activity they will transition to): 

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Offering Choices 

Example Language 

1.  I understand transitions can be hard. Do you want to transition in 1-minute or 2-minutes? 
2.  I hear you that you are frustrated because you cannot keep watching TV. Would you like to watch one more episode before we 

transition or watch an extra episode tonight when we get home?  

3.  I am going to set a timer to help us transition. Do you want me to set it for 2-minutes or 3-minutes? 

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